House Standing Committee on Health

Thank you. Good morning, everyone. Welcome to this 9am hearing of the House Committee on Health and House Committee on Labor. On behalf of myself, Gregg Takayama, and Chair Sayama from the Committee on Labor, would like to welcome all of you for being here to testify, especially nurses. We know how precious time is for all of you.

Just some House rules if I may. To allow as many people as possible to testify, we do have a two minute suggested time limit. Ask that you try and abide by that time. Also, for those on Zoom, and there are quite a few, if you're disconnected, you can attempt to rejoin the meeting.

If you're disconnected, we'll allow you to testify as long as time permits. In the event of a network failure, it may be necessary to reschedule the hearing because we are required to be available on Zoom. Finally, for those on Zoom, please avoid using any trademarked or copyrighted images because that will take us off YouTube.

So let us begin. We have a single measure on the agenda, which is House Bill 1244 relating to labor standards at health care facilities, also known as the Nursing Staff Ratio Bill. So first up we have Director of Labor and Industrial Relations, Jade Butay.

Good morning, Chair Takayama, Chair Sayama, Vice Chair Lee Loy, and Committee Members. I'm Jade Butay, Director of the Department of Labor and Industrial Relations. We stand on our testimony in opposition. This is beyond the scope of our jurisdiction. Moreover, we don't have the domain knowledge or the technical expertise. I think the standards are better negotiated in a collective bargaining. Thank you.

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

Thank you, Chair, Vice Chair, Members of the Committee, for the opportunity to testify on this measure. We are opposed to the rigid staff ratios in this measure. We and our members organization share the goal of providing high quality patient care and taking care of our healthcare workforce.

Experience in other states have shown that rigid patient to staff ratios do not solve the nurse workforce shortage, and further, these rigid ratios inhibit innovation in the healthcare field, especially as technology advances. We're very concerned that the current administration, federal administration and Congress will further cut spending for nonprofit and safety net hospitals.

And unlike private businesses, hospitals cannot readily raise prices to offset labor costs. We strongly believe that passing legislation to mandate ratios is not the way to move forward and that the issue should be left to the collecting bargaining process. Collective bargaining in a number of Hawaii hospitals has been effective in establishing staffing frameworks that consider local needs and workforce realities.

The Legislature can support the nursing workforce, as you have done so, by investing in solutions such as expanding education programs in our public high schools, community colleges, and universities, and by supporting education debt repayment for health care workers. We are very appreciative of your support on these initiatives. We urge deferral of this measure and encourage continued collaboration between management and staff. Thank you for the opportunity to testify.

Thank you very much. Hawaii State Center for Nursing in support. Sorry, you're on Zoom. Go ahead. Please proceed.

Thank you. Yeah, Aloha, Chairs, Vice Chairs, and Members of the Committee. I'm Anne Scharnhorst. I'm the advisory board chair for the Hawaii State Center for Nursing. Hawaii State Center for Nursing stands on this testimony offering comments. Currently, the Center is invested in a number of activities that we hope will improve the stability of our workforce. We are supporting nursing education initiatives, nurse residencies, nurse specialty transition to practice, and wellness initiatives.

They are having a significant impact. The Hawaii State Center for Nursing recognizes that nurses are facing an incredible challenge as the duty to care only increases. Therefore, we're seeking to develop strategies that address workload factors, which include patient care, but also non-patient care responsibilities. We're committed to the nurses in our state and thank them for all their work and service. Thank you.

Thank you. On Zoom, I believe we have Straub Benioff Medical Center, Andrew Moats.

Good afternoon, Chair, Vice Chair, and Committee Members. This is Mike Robinson on behalf of Andrew Moats and Straub Benioff Medical Center, who could not be here today. You have my testimony that I've submitted in writing. I just want to note that most of the elements, if not all under HB 1244, items to staffing ratios, lunch breaks, overtime, they're all elements that are discussed and bargained for under labor negotiations and incorporated into our labor agreements.

I think the execution of our recent labor contract between our sister hospital, Kapiolani Medical Center, and the various unions that represent our healthcare workers demonstrates that that process does work. We believe that the attachment, the enactment of a statutory requirement to introduce elements that have already been negotiated between private parties, that it's going to serve as a bad precedent for employer relations that could extend beyond health care in the acute care sector and beyond.

I also want to make a note that it's really challenging to establish fixed statutes to govern something as fluid as the operations of a hospital in the private sector. I think of the most recent New Year's Eve tragedy. Straub Medical Center has the only burn center in the Pacific.

And you know, within an hour, we had 10 patients admitted into our burn center. Staffing ratios that are fixed into statute would not be able to respond or reflect to a tragedy like that, and we would be out of compliance. And that's just one example. It does. That's a very extreme example. And I'll just end by saying that, you know, fixed ratios unfortunately do not magically create the workforce that's needed. I agree with the statements that were made prior with the Center for Nursing.

We encourage that the Legislature continue to fund and support all of the vast partnerships that are occurring between DOE, the Healthcare Association, the Center for Nursing, the School of Nursing, and the provider initiatives that we've taken to grow our workforce. I think that is the root cause of a lot of the tension that's occurring now. And if we, if we focus it there, I think we're addressing it where it needs to be. Thank you very much for this opportunity to testify.

Thank you. Next, we have Pride at Work Hawaii on Zoom. Okay, here you are.

You brought me off the mountain. Michael Golojuch, Jr. He/him pronouns. I'm President of Pride at Work Hawaii. We stand in strong support of this legislation. I find it ironic that people are touting what happened at Kapiolani Medical Center. It was an abhorrent situation when they locked out the nurses when they did their legal right to do a strike. So let's not. They should not be touting about it at all. I just find that absurd. What we're talking about here is making Hawaii safer. When our nurses are not safe, none of us are safe.

You could do all the training, all the extra education you want, but when nurses get burnt out, and that is what is happening, when they leave the profession because they're getting burnt out because of the patient nursing ratio, you can train them all you want, but if you keep on burning them out, you're not going to be able to replace them fast enough.

When nurses have to sleep in their cars after working double shifts and then get kicked off property, that is not helping Hawaii. That does not make Hawaii safer. So on behalf of Pride at Work, we encourage you to pass this bill. This is not only for those in the yellow shirts here today, but for those that do not have a union behind them to support them and to make sure those patient ratios are safe across the state, not just at a case by case ratio. Mahalo.

Thank you very much. Next, we have Joan Kanemori, Kapiolani Medical Center.

Good morning, Chairs, Vice Chairs, and Members of the Committee. My name is Joan Kanemori. I have been a nurse for over 35 years, I've worked long hours at the bedside in a hospital, as an instructor for nursing schools and academic settings, and within the outpatient clinic home care, as well as a nurse administrator.

I'm testifying on behalf of Kapiolani Medical Center for Women and Children in opposition to House Bill 1244. As the state's only full service maternity, pediatric, and newborn specialty hospital, we do not divert care for our patients. The bottom line is that strict adherence to the staffing ratios outlined in this bill will lead to delays in moving patients within the hospital and patients receiving the care they deserve.

There will be longer wait times in the emergency department, backups for surgical recovery rooms, and delays for patients from the neighbor islands when they require care within the hospital, including intensive care. Currently, if a baby is born prematurely in labor and delivery, say two months early, that neonatal newborn intensive care unit will make room for that baby. Strict adherence to the staff ratios will penalize the hospital for making that happen, and that could lead to interference with this process.

This bill will remove the flexibility required to properly support doing the right thing for the patient. Within our current contractual agreement recently ratified and approved by Hawaii Nurses Association, we are working with our nurses through a staffing council to ensure appropriate staffing that is flexible and fluid, to ensure appropriate staffing that is flex that can meet the patient's needs throughout our community.

Our council considers our staff expertise, guidance from national standards, physician direction on patients' care, and ensures appropriate distribution of care provided to all patients. Patient care and nurse to patient ratios are best resolved at the unit levels for each health care system where physicians, nurses, technicians, social workers, and the entire healthcare team work together to find solutions. This is not a simple issue to resolve and should not be regulated within one discipline. I want to thank you for this opportunity to testify, and available for questions. Thank you.

Thank you. Next, we have from Hawaii Pacific Health, Amy Thomas.

Good morning, Chairs, Vice Chairs, and Members of the Committees. My name is Amy Thomas. I am the System Chief Nurse and Director of Clinical Education for Hawaii Pacific Health. I've been a nurse in Hawaii for 25 years, with 22 of those years at HPH. I work as an adjunct faculty member at Hawaii Pacific University, teaching in the School of Nursing for the past two decades. I am here today testifying on behalf of HPH in opposition to HB 1244.

I want to start by saying that we are all in favor of safe staffing and what is best for our nurses, our patients, and our community. We stand by the latest evidence out there that shows that having unit based staffing levels that are adjustable based on the needs of individual patients as well as the composition of the care team members are the best way to go.

We already addressed the provisions of this bill in our collective bargaining agreements with the Hawaii Nurses Association to include staff staffing committees, a staffing matrix with mutually agreed upon staffing levels that are based on acuity and also based on national standards.

Mandating fixed ratios in a time our state is facing health care worker shortages only worsens the problem and sets healthcare systems up for failure. There are several efforts underway, as mentioned today in other testimony, and I'd be happy to talk about how we are training in our high schools. We're embedded in every school of nursing on the island and that we partner as faculty to help our nursing schools with faculty shortages. So please, I'm available for questions for that if needed.

I also want to mention that we have a significant amount of work that is occurring with innovations in healthcare that focus on decreasing the work burden for our nurses, using technology to decrease the documentation demands, getting rid of inefficiencies in our work, and focusing on redistributing non-nursing related work to other healthcare team roles since we all care for patients as a team. I'd like to thank you for the opportunity to testify, and I'm available to answer questions, as I mentioned. Thank you.

Thank you very much. Before we go on to the next page, just want to note we have written comments in opposition from Hawaii Healthcare Systems Corporation, Wilcox Medical Center, Pali Momi Medical Center. And in support from UPW, United Public Workers, Hawaii Nurses Association. Stephanie Carlini in support from Hawaii Nurses Association, Greg Schumacher, and Kauai Mental Health Advocates. All written. Next, we have, let's see. Rainbow Family 808, Carolyn Golojuch on Zoom. Not present. Hawaii Nurses Association, Linda Beechinor.

Thank you, Chair Takayama and Chair Sayama. I just want to correct a small error there where you called me up as the Hawaii Nurses Association. We are the Hawaii American Nurses Association, and we're the American Nurses Association Chapter in Hawaii. And we speak for the 17,000 registered nurses who live and work in Hawaii.

We are offering strong support for this bill in advocating for all patients in Hawaii health care facilities to be cared for safely by registered nurses. Nursing workload is a wellness issue in our profession. It directly impacts the resilience of nurses and our ability to retain nurses in the profession.

I've been a nurse for more than 50 years, 40 of them in Hawaii. I implore you to listen to nurses who are telling you that their work conditions are untenable. And we are advocating for patients, which is our professional ethical duty, to advocate for the safety of our patients.

Hawaii ANA respectfully requests that the Committee Members work with us to advocate for nurses' and healthcare workers' safe working conditions and conditions that promote safe and optimal patient care. We thank the Committee for its Commitment to the people of Hawaii. Thank you.

Thank you. See on Zoom, I believe we have Hawaii Nurses and Healthcare Professionals, Madeleine Patoc. Please proceed.

Hi. Good morning. This is Madeleine Patoc. Good morning, Honorable Chair Takayama and Sayama and other Committee Members. My name again is Madeleine Patoc. I've been a registered nurse...

I'm sorry. I got your name wrong. Yep.

Oh, no, it's okay. No worries. I've been a registered nurse for 22 years. I'm a 45 year resident out here in the Ewa Beach community. Each time that I would go to work, whether it's three to five days a week, I would have that expectation when I get there that core staffing would be filled.

But more oftentimes than not, we would be short staffed. And then, therefore, we would have to perform the tasks of more than one person, which would then give our patients less than what they deserve. They deserve the most empathetic, most compassionate, and most importantly, the most safest care possible.

Imagine if we were staffed to the core every day, the type of care that we would be able to provide our patients. As a union official and a union steward, I go and I visit with our members and they call out, you know, their cries are out there, they call out, what else can we do? They're emotionally and physically burnt out.

I look for the day that I can give them the good news that there is light at the end of the tunnel, where each day that they go to work to do the care that they do as healthcare professionals that they are staffed, you know, their core staffing is met. So thank you again for giving me this opportunity to share my story and use my voice. I ask to strongly for you folks to support again to continue to move House Bill 1244 forward. Mahalo.

Thank you. Also on Zoom, Hawaii Association of Professional Nurses, Jeremy Creekmore. Not present. Hawaii Nurses Association Local 50, Rosalee Agas-Yuu.

Thank you very much for allowing me to speak today. I was here a year ago and I spoke to this. And I want to say we did, we went back, the nurses went back and we followed. We said, hey, we'll work it at the bargaining table.

I work at Kapiolani Medical center with Joan Kanemori here, and we were locked out for 22 days after a strike. Is that what it takes to get this known? Nurses, it's in our blood to advocate for our patients, and that's what we're doing. When you see us out there, that is what we're doing.

Queens, 1900 nurses, they're feeling the same pain now. I flew over to Wilcox before they struck, and I asked him, is it worth it? You're gonna strike and you might be locked out because it was Hawaii Pacific Health that locked us out. And they said yes, because it's our patients, it's our community.

So if you take anything today, know that it's for the community. Bargaining, it didn't work. It did not work. Patients suffered. We had the patient pass away. It's not worth it if you can prevent it. That's what the nurses are saying. They are trying to prevent it. They weren't willing to work in the bill.

There is a place that we can work together with the people, with the employers. It's not strict when things happen in the community the nurses will come to call. They will adjust. You saw it with the fires. They will call. You weren't there on the chats.

All the nurses were getting called in because it was an emergency. That's not shared. Any nurse that is in this room, if there is something that to be needed, they will come. So please, we're not there. We know that patients need to be taken care of everywhere in the State of Hawaii. Look at Wilcox.

Just because they're there, miles away from us, they need to be heard. And we're making the statement today. So thank you very much for your time.

Thank you. From the Queen's Health, I'm going to ask no applause, please, for either, for or against. Queen's Health Systems, Jacce Mikulanec.

And prior to the ratios that we received with our last contract, the NICU was a highly stressful place where nurses had to make a choice of which baby to literally run to when the heart rate and the oxygen levels drop.

Aloha, Chair Takayama, Chair Sayama, members of the committee. Jacce Mikulanec, on behalf of the Queen's Health Systems, we are in opposition to this particular bill, but we would like to recognize the fact that we share the sentiments of all those that are here testifying today, especially on the nurse, nurses side.

We were very pleased to come to an agreement with HNA and with our nurses staff, with the nurses at Queen's recently that took over 40 meetings. But we feel like we came to a good agreement which included a framework that includes nurse staffing ratios. Please just note that staffing is a very dynamic process.

As many of my colleagues have already stated, it should be based on looking at acuity, changes of patients in the hospital. And that obviously changes from minute to minute, hour to hour, and we need to be very cognizant of that.

We would urge the committee to think about investments in developing our workforce, whether that's the loan repayment system that's been very successful. Over 375 Queen staff have taken advantage of that system and we believe it's having real impact on our workforce. We would also note that we are under a number of federal and state guidelines around staffing.

The Joint Commission has an impact on that. For Queen's in particular, we were just made, redesignated as a magnet hospital. That's an international designation which notes our superior nursing processes that are in place and the dynamics that are involved with that. We appreciate you taking this issue up and thinking about it.

It's a very serious issue and we will stand on the rest of our testimony. Thanks very much.

Thank you very much. Next up, we have Rowan Funes, United Nurses Associations of California, Union of Healthcare Professionals.

Aloha, guys. My name is Rowan Funes. I'm an emergency room nurse over at Maui Memorial Medical center on Maui. This crucial legislation represents a transformative step toward improving the safety, quality, and overall outcomes of patient care in our state's hospital.

By establishing enforceable nurse to patient ratios and accountability measures, this proposal ensures that Hawaii patients receive the care that they deserve. There have been numerous shifts in the Emergency Department this year. The staffing was at dangerous levels.

For example, 1 RN having to manage a trauma critically ill patient alone and essentially keeping that patient alive, while another RN manages the rest of the seven patients in that area of the ER, some also critically ill. It is unsafe and emotionally demoralizing for an RN to not be able to provide the care that their patients deserve.

It is unsafe and dangerous for the patient and increases the risk of harm and or up to even death. Safe staffing ratios is common sense and the correct solution for the staff and the community we serve.

In rebuttal to the gentleman that was talking about Straub and the unfortunate New Year's Eve incident here on Oahu, I was off the afternoon of the Lahaina fires and we all got texted, you know, hey, can you guys come in? We have a situation in Lahaina and everybody came in, everybody came in from the ER.

Everybody came in on the floors. We're not talking about emerging situations and staffing because that's not an issue. Nurses are here to help. We're here to take care of our community.

We're talking about that one day you or your family could be in the hospital and would you want to be taking care of an overworked, overstressed nurse or one with adequate patience, adequate ratios, you know, able to really pay attention and provide the care that you guys need? Thank you very much.

And on behalf of UNAC/UHCP. Yeah, that's it.

Thank you. Next we have Eric Robles.

Good morning, Chair Takayama, Chair Sayama and vice chairs. Eric Robles here with the UNAC/UHCP. We represent also the nurses in Maui, Maui Health. You know, I submitted comments, but I really wanted to recognize that patient safety is not a collective bargaining issue.

There are about 5,000 nurses that collectively HNA, HNHP and UNAC/UHCP represent about 5,000 nurses. But there are 17,000 nurses here in the State of Hawaii. There are more places that are, don't have unions. And where you don't have a union, you may not have an agreement that deals with staffing ratios.

So I would submit that staffing ratios is not a collective bargaining issue. Patient safety is not a collective bargaining issue because there are other places where unions don't exist and they don't have a chance to have a collective bargaining agreement. Thank you.

Thank you. Melissa Robinson.

Hi, good morning. My name is Melissa Robinson. I am a nurse at Maui Memorial Medical Center. I'm also the cochair for UNHCE, which is an affiliate of UNAC/UHCP.

As a registered nurse with over 15 years of experience, I have witnessed firsthand the critical impact that staffing ratios can have on patient care, safety, and overall well being.

Working short staffed has been an all too common occurrence and I can attest that it poses a significant challenge not only to nurses, but, but also, and most importantly to our patients. When staffing is insufficient, it becomes nearly impossible to provide the level of care and attention each patient deserves.

Nurses are spread too thin, trying to juggle numerous critical responsibilities simultaneously. This often leads to high stress levels, burnout, and a sense of helplessness when we cannot deliver care up to the standards we strive for. The reality is stark.

When we have more patients than we can reasonably handle, we are forced to prioritize duties that should never have to be, never have to compete for attention. Such as administering medications on time, monitoring vital signs, and providing comfort and education to patients and their families. The consequences of inadequate staffing ratios go beyond potentially compromised care.

They also increase the likelihood of errors. Errors that can have serious and sometimes irreversible consequences. A missed deterioration in a patient's condition, a delayed response to a call bell, or a mistake in medication administration. These are risks that arise as the nurse patient ratio increases beyond safe limits.

Conversely, in environments where staffing ratios are maintained within safe bounds, the change is palpable. Nurses have the ability to conduct thorough assessments, engage with patients and understand their needs holistically, facilitate effective communication among healthcare teams, and prioritize preventative care activities that greatly improve patient outcomes.

The moral distress that often accompanies the inability to provide adequate care is alleviated. Patient safety and positive health outcomes should always come first. Inadequate staffing ratios are fundamental to achieving this objective.

By supporting safe staffing ratios, we elevate the standards of patient care, reduce nurse burnout and turnover, and ultimately foster healthier environments for both patients and healthcare providers. The difference these ratios make is not just noticeable, it's transformative. Safe staffing ratios are a necessary investment in the well being of both patients and caregivers alike.

Please support this legislation to build a healthcare system that protects vulnerable residents and supports caring professionals. Together, we can assure all patients in Hawaii receive the quality, compassionate care they deserve. Thank you.

Thank you very much, Daniel Paul Ross.

Good morning. I'm Daniel Ross, RN. I'm a constituent of Representative Sayama. As you may remember, we met at a recent event for the Center for Nurses and we had some discussion at that time.

I'm the past President of Hawaii Nurses Association and I have worked as a bedside med surge nurse for 40 years, the past 33 years at Queen's Medical Center. So I have been in the trenches for 40 years. Even as President, I continued to work as a bedside nurse. I know what I'm talking of from experience.

I strongly support this bill, as does virtually every hospital bedside nurse. The gaslighting that goes on from hospital leadership, including non direct care patient nurses, patient care nurses and their surrogate organizations. The bill has a history of gaslighting the public ratios are not inflexible. They can be adjusted as needed for increased needs.

It is simply the floor at which you could have the minimum number of nurses taking care of a set number of patients in particular, particular settings. It's going to be different floors for different type of settings. Right? The shortage of nurses is a myth. We don't have a shortage of nurses.

The reality is there's a shortage of nurses willing to work at the bedside in these current conditions. We've got a lot of nurses here, I bet a lot of them that are advocating on the other side of the issue either never worked at the bedside or it's been many, many years since they've worked at the bedside.

This legislature last time came out with a very good study, a time for triage. I hope every one of you have seen it. It was put out the last time because we've done these bills multiple times to try to get something through.

In that study it showed that more than half of the new nurses leave within two years. This means that the government's and the schools' past attempts to address the issue by producing new nurses ineffective and will leave us with a very inexperienced nurse workforce.

We need to encourage and have new nurses going through, but we also need to encourage and maintain our experienced nurses and recruit more experienced nurses to mentor those new nurses and create a work environment that will keep them and not have them leaving within two years. It's unsustainable.

The recent and ongoing hospital labor unrest is a direct result of the past failures of the legislature to act effectively. With some lawmakers denying that this is a legislative issue and instead saying this is a contractual one. Do the patients in non union hospitals not deserve the same level of safe care as those in the union hospitals?

We all witnessed the recent despicable behavior and gaslighting and misleading statements from Kapiolani leadership during their strike and lockouts. They had to endure in their fight for basic patient safety.

I'm going to ask you to please summarize.

Does every hospital nurse have to experience the similar abuse from their hospital leadership as the Kapiolani nurses did for their patients. Our community deserves safe hospital care. We're caring for some of the most vulnerable members of our community.

The hospital's actions have demonstrated their priorities are generating revenue to maintain multimillion dollar compensation for their top executives. Not to single out HPH, when Queen's relatively new CEO joined Queen's as the CEO some years ago, his mandate was to cut costs. This was achieved in part by cutting nurse staffing.

I'm going to ask you to please summarize

And not filling vacant positions. He told me to my face that it's going to be cheaper for him to overwork nurses and create overtime than it is to hire new staff.

Thank you. Thank you, Mr. Ross. On Zoom we have Matthew Michalak, not present. Charlene Pang, in support. You know that's all the test cards I have listed as being present either in person or on Zoom. Have I missed anyone in the room or on Zoom who wishes to testify on HB 1244? Yes, sir. Please identify yourself.

Yes. Morning, chair. Oh, technically chairs, representatives, and everybody in the room. I'm Kalani Werner. I'm the state Director for United Public Workers. We represent over 13,000 public workers. But what most people don't know is we actually represent 14,000 nurses in public and private. We submitted written testimony today and we stand in strong support of this bill.

And, oh, let me just get through. I want to say clarify, because what I heard today, what I took offense to is the collective bargaining. We've had it in the states since '68. It's been rooted in Hawaii's history as a strong union state.

And yet when we go to the table, guess what is the first one when it comes to the medical field that the employer wants off the table? The ratios. Something nationally, in New York, they went to the strike line not because of the pay raise. They was offered a large pay raise.

They went to the strike line over the ratios, the safety of the patients. You'll never hear anyone in the medical field ever say, I can't do something because my contract doesn't provide for it. When you're needed, your patients are your number one concern. They're always referring to them as family.

I know all the nurses when I was in the hospital. I know my nurse's name, Destry. She took care of me. Family was not allowed into the room, but that's how much she took care of me. That to this day, I remember her name. How overworked she was, how over short staffed they were.

She still made sure the rounds was made to see and make sure I had that care. So to say that the route is collective bargaining is not there. It's one of the first to come off the table to say that you're worried about the care a patient might be provided, that's misleading. That's a straight out lie.

Everyone in this room wearing a yellow shirt would guarantee being that room to help those individuals in a heartbeat, regardless of the situation. When the emergency arise, we always step up to the occasions. And lastly, you always see these slogans. UPW has a slogan for our medical field. Don't look at the bottom line.

Don't protect the bottom line. Protect the front line. These individuals that just want to be recognized and respect in the work they do. Because in our, let me, I got a little bit emotional like my other sister over here. Let me just put this out there. Born and raised a Christian.

They're doing God's work, taking care of our ill, our sick, and our dying. And they're the ones, if someone's there alone, holding their hand in the last moments. They want to be able to show the respect and this is something every union out there has fought for. And yet it's still not in the language.

We've gone to strike lines for 52 days over this issue and still not in the language. We look to you for help now. Thank you.

Thank you. Anyone else I please. Anyone else who wishes to testify, please step forward and identify yourself.

Good morning, chairs, vice chairs, committee members. My name is Sarah Beamer with UHPA. We stand on our written testimony and strong support. However, I just wanted to highlight that not all of Hawaii's hospitals are unionized. So leaving up standards of care for patient safety cannot be left to collective bargaining alone. Thank you.

Thank you. Last call. Yes, please.

Thank you. My name is Amy Brown. I am a registered nurse at Kapiolani. I have been a nurse for 20 years. 17 of those years have been at Kapiolani. And prior to the ratios, I work in the neonatal intensive care unit which is caring for babies that are born from four months premature to just having congenital issues when they are born.

I submitted a testimony on a positive patient experience that occurred after the ratios were enforced. The current standards of the employer is to mandate overtime if three ratios are not met.

I live an hour away from work on the North Shore and I also work overnight from 7pm to 7.30 AM. Driving home after 16 mandated hours is not, is unsafe. I really don't need to tell you that. And I have known people who have left because it's not healthy.

It's not healthy for your family, for the patients, for the people on the road. Nurses are leaving the field of the nursing field because of overstressed workplaces. If the ratios are not met, there will be a financial penalty if this law passes. Rather than turning away patients. Nurses will never turn away patients.

Nurses love what they do because we like taking care of patients and we liked seeing people getting well. So I am in support of this bill because Hawaii nurses are being forced to bargain for safe workplace and providing proper care to their patients every three years.

And that is also a very highly stressful situation to be fighting every three years for a good work environment. Thank you.

Thank you. There being no more testifiers, members open it up for questions. From either health, yep, or labor. Please proceed.

Can I ask a question to Healthcare Association of Hawaii?

Hi, Mr. Raethel. Hi. I want to ask you about your written testimony. In your second paragraph, you stated that codifying rigid staff ratios will exasperate existing challenges without meaningfully improving outcomes. What I found was that there was evidence-based research contrary to your statement.

What I found that is, was that patient nurse to patient ratios improve hospital mortality rates, shorter length of stays, fewer patient falls, and lower hospital-acquired infections.

I also reviewed a time and triage report written last year by our very own Legislative Reference Bureau supporting the claim that lower nurse to patient staffing ratios will reduce burnout and increase nurse retention. Everything I mentioned would be positive outcomes for our state. So can you tell me what outcomes you were talking about in your written testimony?

I don't have all those studies that you referenced, and I'd be very interested in looking at them. Patient safety is an issue that we as an association and we as members take incredibly seriously. Every hospital in the State of Hawaii is a not-for-profit hospital.

It has leadership who live in the community, work in the community, and whose family members experience care in these various facilities we're talking about. They are absolutely committed to quality care. Now, in terms of ratios, and there are ratios, mandated ratios in a couple of states, California being a quintessential example. There's some ratios in New York.

And we could talk at length about the consequences or the lack of consequences of those ratios. Fixed ratios do not conjure up staff. They do not create new staff. California's vacancy rate in their hospitals and California pays the highest nursing salaries in the country. They have a vacancy rate similar to what Hawaii does.

Yet they have had mandated ratios for 20 years. It has not solved their nurse staffing problem. Neither has the fact that they pay the highest in the country. It would be great on the nursing unit, on a med-surg unit, if we could assign a nurse to every single patient.

I mean, that would be phenomenal for the patient and for the nurses. So you've got two questions. One of those is, where did those nurses come from? We have a national shortage of nurses, we're all talking about. And nurse staff ratio, I mean, our nurse turnover rate has actually gone down over the last five years.

It hasn't gone up, it's actually gone down without the use of ratios. So could it be better? Yeah, could be better. The cost of living is a huge issue. So if we added a lot more staff to our hospitals, assuming we could even find the nurses, then we have to pay for them.

The question is, where does that money come from to pay for them? Hospitals cannot just raise their price like a hotel. The hotel when their workers go out on strike, they can raise their rates and they charge the public more to go and stay at their hospitals. We do not have that ability.

So it is a balancing act every single day that our hospitals, who are committed to our community and our nurse leadership, who are absolutely committed to our community and safe staffing, they are working every day to say, with the resources we have, what can we do? And with the skill mix we have, what, what can we do?

Do they take their job seriously? The fact that they have not worked for five years or 10 years and nursing leadership on the floor, they are still absolutely committed to taking care of their staff and their staff ratios. I would be interested in looking at these studies.

We just know that in New York, for example, where there is some mandated ratios there, it has not solved their problems. California, it has not solved their problems. We are working to solve the problems and the hospital leadership is working to solve those problems with the resources we have.

Okay, so I just want to make sure that the meaningful outcome was going to be, first and foremost, patient safety and not the bottom line. Is that correct?

Absolutely. Our hospitals are not for-profit hospitals. None of them, you know, our leadership does not benefit.

I don't work in a for-profit setting, so stock options and all the benefits they get from, you know, from a more positive bottom line and squeezing the bottom line, that does not happen in Hawaii. We do not have a single for-profit hospital here in Hawaii.

Thank you.

Thank you.

Thank you. Any other questions? Representative Garrett.

Thank you, Chair. Mr. Raithel, if you don't mind coming back up to the podium, please. You know, just setting aside the merits of the underlying bill, I mean, clearly we're hearing from our friends in yellow here that they're dealing with burnout, stress, morale issues.

And besides wages, can you educate the committees on what the sector is doing to support our registered nurses and make sure we don't lose any or none leave the profession?

There are many issues and thank you, Mr. Garrett, for the question. Representative Garrett, there are many issues that impact stress for nurses and any health care worker. One of those is the cost of living, cost of housing, cost of a dozen eggs right now, which is.

But in regard to workforce, our hospitals, again, they're not for-profit hospitals; they are all community hospitals. They're here to serve the community. It's not in their best interest to have high turnover rates, to have a workforce that is dissatisfied. That doesn't make sense. It doesn't make economic sense, doesn't make logical sense.

So are they committed to their staff? Absolutely, they're committed to their staff. You heard from the Hawaii State Center for Nursing, for example. That's a phenomenal professional organization dedicated to improving staffing in Hawaii, providing training, providing education. Our hospitals, in terms of violence, for example, and that's a significant issue.

Unfortunately, hospitals can be very stressful environments for patients, for visitors. And so we spend a lot of time and energy as an industry working to educate nurses, security staff, other therapists, technicians on how to deal with stressful environments, how to de-escalate violent incidents.

There is, in terms of nurse education and providing nurse education, there is hundreds or thousands of hours of nurse education, continuing education provided every year by these organizations to support our health care workforce, to educate our workforce, to allow them to grow professionally. And we could give you specific information if you're interested.

There is a huge amount of work that takes place every single year to support our workforce, to look at benefits, to look at what does it take to keep our workforce intact?

You know this theory out there that hospitals are all focused on the bottom line, that it's all about squeezing out the dollars. Hospitals exist; you look at their mission statements, they exist to serve patients in their community.

That's their very reason for existence. So they are committed to the workforce and they are committed to their community and they are committed to safe staffing and high quality care.

Okay, thank you. Thank you, Chair.

Thank you. Any other questions from Members? Yeah, Representative Martin.

Sorry, one more time. You know, it could be a question for any of the hospitals, but because you potentially have a look at all of them, looking at the ratios that are in this Bill, starting on page five, the minimum registered nurse staffing standards, are those standards excessive?

Are those the standards that you would like to see ideally in a hospital? We're not necessarily good at judging that, right?

Those of us, which may be all of us that have never worked in a hospital or been a nurse, we may not be able to assess if those are reasonable or not, but are they reasonable, safe standards for a minimum?

Our hospitals are absolutely committed to safe staffing. Right. We actually use all of our hospitals, whether they're unionised or nonunionized, right, it doesn't matter if you're unionised or nonunionised. Every single one of them is still committed to safe staffing. So in terms of safe staffing, do they look at national standards? Absolutely.

They're aware of what the national standards are, right? For different units, ICU, NICU, CCU, telemetry, you know, med surg, all of those units. They look at those staffing ratios. There's a couple of critical factors that need to be taken into consideration. One of them is the acuity of the patient.

If you've got a 70-year-old patient with pneumonia and they have diabetes and hypertension, and then you've got a 40-year-old patient with pneumonia, that 40-year-old patient with no other comorbidities is going to require less care than a seven-year-old patient with comorbidities.

So you've got two patients with pneumonia, just one patient, the patient with the comorbidities, the 70-year-old, is going to require more care than that 40-year-old patient. So you need to be able to adjust.

And that's why our nurse managers, working with the nurses, adjust that care to say what's the acuity level at any given time on a unit? Throughout the day, the evening, weekends, whatever. And they adjust their staffing as appropriate. So that's one critical factor which is the acuity of the patients on the unit.

And so you've got this base level that everyone understands. These are ratios we should have. Then you need to be able to flex based on again, acuity is one, the other one is the staffing levels.

We've got nurses, fantastic nurses, been here 15, 20, 30 years, and you've heard from some of them today; they have a lot more experience, right? They can take more care, they can make decisions more quickly because they've got all those years of experience.

If you've got more experienced staff on a unit versus staff who've only been there for one year or two years after they've done all their in servicing and training, they cannot carry that same patient load. So the experience level of the staffing on a unit along with the acuity are two variables that vary shift by shift.

So you have staff coming and going 10-hour shifts, 12-hour shifts, whatever the shifts are, you have different mixes of staff, you have different mixes of patients, patients are going in, getting admitted, patients getting discharged. All those factors are varying. So we all know, everyone knows what those base levels are.

And then you use those as a baseline to say, okay, how do we adjust from there? That's our concern with you folks, as talented as you are, right, making a decision about you know, one to five, one to six, whatever the number is. The hospitals know the ratios. They've got staffing through collective bargaining.

They negotiated staffing committees, and that's where they look at those national baselines and then say, okay, what's the acuity level? What's our staffing level? How many new nurses do we have? How many CNAs do we have to provide additional support to take some of the load? How are we using technology? All of those factors go into play.

But is there a baseline that we all use right now? Absolutely, that is being used.

Is this that baseline? That's my question.

What is that baseline?

No. What is in this Bill, does that match the baseline?

I'd have to check on that, but I'm happy to check on that and get back to you.

Okay, thank you.

Thank you.

Any other questions, Members?

Representative Kapela, did you have a question?

Oh, no.

Yes. Okay.

I wasn't sure you looked expectantly.

I'm trying to think about the best way to shape my question. Thank you, Chair. I think my question is for, I think my question is for Kapiolani, if anyone from Kapiolani is still available? Thank you. I want to thank all the testifiers as well for being here, both for and against.

I do recognize that our hospitals are, you are also trying. But from the very passionate testimony of our nurses, I think there's a lot more that needs to happen. My question, though, is, we just heard that there's this national shortage of nurses.

Yet to my knowledge, scabs that cross the picket line when nurses are picketing to get better conditions, like are requested in this bill, or potentially traveling nurses make more money than the nurses who are here that are working with our community, working for our community.

And it was really bothersome during the last nurse shortage or the nursing strike at Kapiolani, when all over social media, there were traveling nurses who were talking about coming to Hawaii and talking about crossing the picket line.

So I guess my really, how much, if it comes down to bottom line, how much are you paying these nurses that are crossing picket lines or traveling nurses, as opposed to our local nurses who are just asking for a little bit more?

And I think the crux of this bill is to ensure those safe protections for themselves and essentially for their patients. So it does come down to a bottom line.

So if you're asking, if you're asking how much do we pay that I would have to defer on that to give you that type of, I don't think that's really the question. Is that the question?

Well, I'm asking, are you wasting more money by paying more money to traveling nurses or scabs than just essentially paying our nurses more to be more attractive? I guess, so that you can fill the staff-to-ratio or staff-to-patient ratio.

Correct. So I do have to say that, you know, we definitely are competitive with our wages. We do look for experience.

There's a like a third that are experienced, third that are getting really good at what they're doing, and then very novice nurses that may take a couple years to get to where they are in terms of care.

In terms of what we're paying, I myself have been on both sides, right, where I want to be compensated, and I want the nurses to be compensated. How much I pay the traveler or the different companies to fulfill that need, it's a supply and demand issue, and what it needs to take to get the care that's needed at the bedside.

I don't want to speak prematurely as to what it costs. I would love to give everybody what they could, but we work within the resources that we have. So I want to go back to when I have nurses that I'm working with that are willing to come in, that can do the work, I have experienced nurses that I'm working with, I almost don't have to do as much when I'm the charge nurse.

But when I have a lot of novice nurses on, I do have to spend more time with them to make sure that the care that's provided at the bedside is adequate.

What they all get paid is going to be different, right? Depending on if they're the charge nurse, if they have more education and experience behind them.

But collectively as a whole, what am I paying the nurses that are at the bedside, the nurses that I need to fill the gap, and the situation that we were in, provide care regardless. Because I have to take that part of it out, because that was something that occurred that we don't want to go into, that we don't want to happen.

And yes, you're right, it's going to cost. It's going to cost. And at what price is that? We have to get the staff at the bedside, regardless of who it is. And social media is crazy, right? Like, I can't control that.

Thank you so much. Thank you, Chair.

Thank you. Members, any other questions?

Representative Reyes Oda?

Hi. I have a question for Rose from HNA.

Oh.

Hi. Thank you. This is about the written testimony from Hawaii Health Systems Corporation, and I believe HGA represents them, but I'm going to ask the question to you just about this area.

In their testimony, they said that if our healthcare personnel feel that they're subject to unsafe working conditions, they have an avenue to protest these conditions through their union representatives. As a person who was on the line at Kapiolani, can I ask you two questions?

Do you know how much Kapiolani spent to lock out nurses? And when Kapiolani did lock you guys out, what message did that send to nurses across the state about protesting their working conditions or safe staffing specifically?

So, first of all, I want to say, you know, the lockout, it's made an impression. It's scored deeply into 600 nurses at Kapiolani. And based on that, I'm going to skip to number two. It has brought the attention to everybody in Hawaii, especially the nurses. I am a transport nurse, I fly across the States.

I pick up sick babies, I pick up sick children. I bring them to Kapiolani, I'm very proud of that. And that way, I have a lot of contact with different hospitals around the state. And I hear from them and I see from them.

And I also am the President of HNA, so I hear from all the nurses how important this is, that they feel that the ratios is so important because they are struggling. And some of them don't have unions, and we can't help them with that. But this is a good way for all of us.

And as you know, we've been working with, you know, the Kaiser union. We've been working with UNAC because it's important. And if you look across the nation, it's important across the nation. The problem is we want to focus here in Hawaii because we're seeing it. I mean, I said it already, like Wilcox.

I mean, that's our sister hospital. And we had ratios for one to four to five for med-surg, and they're fighting just to get five because they want six. And how is that different? It's not. It should be the same, the same standard. In terms of safe staffing, we do have a way with safe staffing forms.

We fill them out in a way that is for nurses to protect their license. That's how we educate. Because, you know, at times the employer decides whether they're going to do something about it or not, and then we have to pursue further.

But the safe staffing forms is a way for nurses to say, hey, this is a problem. Our license feels like it's in danger. So we are just letting you know that we protest this assignment. But because we are nurses, there's no one else that's going to take care of that patient.

I think it's what's left is unsaid, is that we will do our damnedest to take care of that patient if there's somebody there that needs to be taken care of during COVID time. And I think that's been the crux of all of this.

We will do what we need to do to take care of that patient that had no family members there, that are going to die, and we will be their family member. We did extremes. Queens, I heard their stories. My dad was in the hospital over there.

I felt it not being able to be by him all the time. I never shared that. It means a lot. And the nurses were struggling. They were just trying to get patient to patient. And it's not only nurses, there's other health care workers that have been affected by this.

And I just want to know that it's doctors, it's our aides, it's anywhere in healthcare profession. But the nurses have taken the stance, and this is the beginning because there is a bigger problem. And I think by the nurses standing up, that we're identifying that there is a bigger problem at hand.

And maybe we'll get more into the crux of it. Because I know you guys are talking about costs. I have no idea, we've asked, we've asked requests for information on how much does it take for scab nurses to fulfill the hospital needs of the hospital.

Obviously, I don't know. Because they also had vacations, and I don't know, in some areas, they had extra bonuses. But how does that feel for a nurse who is standing out on the lines, saying patient care is important for Kapiolani? I can truly say, because I am one of them, that it was number one.

The money didn't matter. It didn't matter. It was all about it. All of those nurses would not have stood up. And that was the beginning because you saw it in Maui. Now you see in Wilcox there's only 140 of them. But it's an impact because you see them and they're by themselves.

And we're trying to tell everybody that's the problem. Why does it have to be a nine month process for bargaining? It shouldn't. This is patient safety, this is the community. It's never been about the money, it's always been about the patients.

Because we would not be here, the nurses would not be here unless it was about the patients. Unless you've been a patient, and I'm glad people have been sharing it. You realize you are the most vulnerable when you're in the hospital. There's no VIP status. You're just a patient. You are important for all of us.

Whether you're VIP or whatnot, you're important. So know that if there's any case where we are not coming to the call because there's a big emergency and there's a fire in a building and nurses aren't showing up, you let me know. Because there is not a nurse, if they can hear the call and they can come, they will come.

That is why we went to nursing school, and we are protecting the people that have been in the profession for a long time. I know they talk about the young ones, they get paid cheaper, but you know what?

What's happening now in the hospitals is you look up and it's all new faces. So you have one experienced nurse taking care of 10 inexperienced. No breaks, no lunch, because they're trying to maintain whatever ratios the hospitals have given us now. So that is what you're seeing, that is what you're not hearing. So, thank you. I hope I answered.

Rose, can I just follow up with one question? If you can answer this with yes or no. You mentioned it, and I wanted to make sure. So when a hospital makes a decision on safe staffing ratios that can affect your license, your career, your livelihood for the future. That's why you guys file those papers?

Yes.

Okay, thank you.

Thank you, Chair. I mean, I'm sorry, Representative Garrett.

Thank you, Chair. Second time. Ms. Thomas, please. Hi there. I know Mr. Raethel's response to my earlier query about what the sector is doing to support your RN workforce dealing with burnout, stress, morale issues. You seem to focus more on professional development.

Can you let us know from your perspective as an RN who works as faculty, now as a hospital administrator, what your system is doing to help the RN workforce deal with these emotional issues?

Sure. So I do know that there is testimony submitted by the Hawaii State Center for Nursing that talks about all the wellness initiatives and the well-being piece. A lot of the work that we see that's being done is around work burden and really looking at how we can support nurses.

In Hawaii Pacific Health, the training and bringing in new nurses is very important to us. I heard the statistic earlier, and I just want to share that our two-year retention rate for our new graduate nurses is 95%. So we actually keep our nurses.

The reason for that really comes around all of the training and the pathways that we have where we're investing in these pipelines to bring nurses in. So in Hawaii Pacific Health, we have our training curricula for nurse aides, medical assistants, surgical instrument processing technicians, and 19 in our high schools in partnership with the DOE.

So those partnerships really bring in entry level professions that then go into nursing tracks and careers. I mentioned that our specialty training academies, we've embedded them in every nursing school on island and so that we have direct tracks right into employment, additional training in our hospitals to be able to really recruit.

The other thing I just want to mention about nurses is we're very evidence-based. And the latest evidence out there for staffing is really about looking at unit-based staffing levels.

And so when you look at flat, you know, fixed ratios across a number of different units, we're really missing out on what the research shows around the unit-based piece, around looking at the patient acuity and the mix of staff.

You know, just in Hawaii Pacific Health, we have differences in our medical surgical units from hospital to hospital, hospital and what we do, the types of patients that we take care of in those units, the skill sets of those nurses, the support systems for those nurses, the composition of the healthcare team, all of those things really matter.

And that's why that unit-based implementation is really important. That's also why in our collective bargaining agreements, we have those unit-based levels that have been agreed upon between our nurses and ourselves that we're always looking at.

In addition, that staffing council to have the voice of the nurse is really, really important so that we can make sure that we're always adjusting in that regard. The last bit of evidence that's out there is really around collaboration, collaboration between nurses and nursing leaders.

And that's that staffing council or in this bill, the staffing committees, those things that we have in place that we're finding really positive movement and success with our recently negotiated contract at Kapiolani. Did that answer your question? Thank you, thank you.

Thank you, Chair Martin.

So some of the testifiers, like for example, the Hawaii Association of Professional Nurses, said that Hawaii doesn't have a nursing shortage, it has a hiring shortage. The nurses are out there, but you folks are not hiring.

I'm wondering, since you represent like Wilcox on neighbor islands for those types of hospitals, are you able to hire all the nurses that you offer jobs to?

Because we keep thinking, oh, we need to train more, we need to fund nursing training, we need to get more nurses. But is it that they're out there, but you folks are simply not hiring them because of the overall hospital budget, as discussed, where you have to make choices within a certain fixed amount of money?

We are actually, and I will say in the last two years, with all of the workforce efforts that we've had in partnership across our state, we have hired more nurses in the last two years than the previous five combined. We have trained more nurses in those two years than the previous five combined.

So the case is that we are actually really bringing in additional staff. In addition, just from the retention side, our retention rates are half, our turnover is half of what is happening nationally. So we know we're trending and going in the right direction.

Healthcare took a hit during COVID, there is no doubt, and we're really seeing the workforce stabilization efforts begin to play out. So I think with that, the latest evidence, the successes that we've seen in partnership, that we need to continue along those lines.

And that's really just a multifaceted approach to this highly complicated issue, and really the direction that we need to be heading as a state, and together, the collaboration.

When you try to hire people, are you always able to fill those positions? That was really my question.

Yes. If we have people that apply into positions and they're qualified, we hire into those positions, yes. Does that answer the question?

I know you hire people, when you put out a bid to try to find staff, are you always able to find qualified people?

I think over the past couple of years, that's a challenge in Hawaii that we've had. That's where the staffing shortages have come about. That's why we've really had to commit to training within our state and that sort of thing.

If we have to bring in travelers to stabilize staffing, we absolutely do that because we have to care for our patients. We can't not. And so we do have to bring in that workforce on occasion, and this is all part of the work to build up.

But, yes, when we have open positions, if we have qualified candidates, we are absolutely training. We're very creative in how we're bringing them on.

So it sounds like the answer is no. Sometimes you try to hire people and there's not a qualified candidate available.

I would say if that is the case, then we would use traveling nursing staff.

I am not asking how you solve it, I'm asking if that situation presents itself.

On occasion, yes, of course, yes. I mean, that's part of the nursing shortage. Yeah, thank you.

Chair Sayama.

Okay. I have several questions and I'd first like to start my line of questioning with regards to the administration of this policy. And so, if actually I could ask DLIR first. Thank you, Director, for coming. You noted in your written testimony that you're opposed to this measure.

I know we've been going down a number of testimonies so far, so I'd like to come back. You know, why are you opposed and what's the rationale behind that opposition?

Well, first of all, we don't have the, you know, expertise. And, you know, I mean usually what, you know, for this kind of stuff, I mean we would look at the, you know, the federal standards. OSHA, you know, they promulgate the standards. And then if, you know, if that is not enough, then we look at the industry consensus standards that regulate these activities. But we don't, we don't have the, you know, we don't have the expertise.

And to clarify, right. And under this measure, DLIR would be in charge of setting these staffing ratios, providing variances to hospitals who apply for them, as well as enforcing these staffing ratios, essentially, right? You're going to be administering this policy unilaterally? You're saying that you don't have the current expertise to do this?

Correct.

Okay, thank you. I'm just going to echo DLIR's testimony with regards to the lack of expertise and knowledge. And given that this bill is all about staffing ratios, I'd like to start by going down the staffing ratios of this bill. So let's see. You know, we haven't heard from Hilton in a while.

Why don't you come back up and if these questions, you know, maybe you can't answer them, you know, I encourage someone else who does have the answers to please step up to the podium. So I suspect, like myself, Members of this Committee haven't been a nurse or a physician or worked in a hospital.

So, if you could maybe clarify some of the technical terms of this Bill. So I think the highest nurse-to-patient ratio in this measure is one to six for postpartum, antepartum, and well baby nursery. Can you explain what that is? Like, what does that unit entail?

It's all about childbirth. So prior to childbirth, post childbirth, and then taking care of the well baby.

And so with the acuity of these, this particular unit be less than, say, the one to four ratio for the oncology unit, right? The oncology is dealing with cancer patients. That sounds pretty serious.

Yeah. So, you know, you're getting at the very essence of ratios.

And going back to my prior comments, you know, if you're talking about, you know, childbirth, if you've got a young, healthy 25-year-old mother who, or pregnant woman who has done all the prenatal checks, has, you know, takes care of herself physically, exercises, eats well, has gone to every single visit, you know, that they need to, right, prior to the baby being born, there's a very good chance that that individual will have a, you know, a relatively simple delivery.

You know, delivery is very complicated obviously and a very stressful event.

But if you've got, so now, say you've got a 25-year-old who is on the streets, maybe using drugs, got pregnant, has not seen a doctor, and then shows up to deliver. The type of care those two 25-year-old individuals will require is very, very different. So again, that goes back to acuity.

Same with oncology. Oncology is incredibly complex, and the variety of patients, cancer patients that you have, multiple factors impact that; age, severity of illness, what level of cancer. So, again, that gets to complexity, and that is what these staffing committees are doing every single day is to say, what is that mix of patients?

What is that mix of staff? And how do we ensure, to the best of our ability,y that we take care of the patients safely that we have? But those acuity levels can vary dramatically.

So yeah, this is going to take a long time if we're going to go down each one. But you know, just for example, right, I don't know what hemodialysis is. It has a one-to-one ratio on this measure, same as an operating room. What's hemodialysis? Why is it so important?

Hemodialysis is around kidney disease, and actually getting dialysis for, you know, for renal failure.

I guess my question is why is it a one to one? I don't understand why.

Because again, that goes to severity. Okay? So someone who's just come out of surgery, especially major surgery, will require a lot of care in the hours, days after surgery, depending on the type of surgery. Someone on hemodialysis, right, is generally, you know, suffering from kidney failure. Okay? So, that impacts different bodily organs. Okay?

And so that's the whole point of looking at those. That's why we have generally accepted ratios that are in place right now. Someone who's on an ICU, an intensive care unit, who is hooked up to a bunch of monitors, IV bags, maybe going through chemo. There is often generally one to one care.

In extreme cases, you could have two staff to one person, someone who's on ECMO, for example, which is, you know, lung and heart bypass. They could have four staff to one patient. So we already adjust on a daily basis staffing ratios based on acuity and based on the level of expertise that exists on these units.

Okay, I'm just curious. So moving away from the ratios for a moment, going back to the administration, hypothetically, if this measure were to pass be signed into law, would Kapiolani, Queens, Wilcox, look to get a variance from these, as it is said in this Bill? Would you guys seek to get a variance from this?

I think you'd have to talk to the hospitals that run the individual hospitals, but the all the hospitals are using right now generally accepted ratios as a baseline and then flexing based on all of these factors, acuity levels, how many novices you have on the unit, how many experienced nurses you have on the unit.

So they would then need to be variances. I'm assuming there would, because these ratios, again, that's the issue with them. They do not take into account all of these different situations.

Oh, sorry. Yes, Ms. Thomas?

Thank you.

Okay, maybe that was a question. Better for HPH. If you could come back to the podium.

So from your experience and expertise, do you believe HPH would be able to meet these staffing ratios set in this measure?

We already staff to national standards and in our. And this alludes back to that unit based piece that we all need to consider. And that's why at our hospitals we have unique unit based staffing ratios and. Levels that we realize that.

But I'm just talking specifically about this, right, you know, the one to two patient post-anesthesia, one to one for operating room, one to four for oncology, so on and so forth. Do you believe that HPH would be able to meet these standards today?

I believe that if there are national standards. I'm not familiar with every one that is in there, but we follow the national standards and I will tell you that some, some national organizations in nursing like our medical surgical areas, they don't have national standards. And the reason for that is because there's.

And their stance is that they do not support fixed ratios because the reason for that is a med surg patient can look so different in every environment across every hospital system. So I feel like I'm not familiar with every number on there to be able to speak to that at this point in time.

But we are committed to staffing to national standards.

Sorry sir, I see you raising your hand. Would you be able to answer this question? Okay, please come up. Sorry. Can you state your name and your organization that you're representing for a moment?

Hi, my name is Rowan Funes. I'm a nurse in the emergency department over in Maui and representing new and ACCU hcp. These standards were done based on studies. They're national standards.

The proof that the hospitals can meet the ratios is that a lot of departments have the ratios, for example, or 1 to 1 don't ever go 2 to 1 on or because it's a moneymaker. ICU is always 2 to 1. They never go over 2 to 1 ICU.

So there's departments that they meet the standards and they never mess with it. It's the other departments, it's the tele, the progressive care unit which is step down icu. It's the med surg nursing. Our ends in nursing does not have a chargeable code on the billing.

So basically as much patience as they can give us, the hospital can make more money. So the way they do it is yes, they try to meet the standards but staffing is usually done at 5am and 5pm every day.

The staffing will look at the house and see what the sentence is like, blah blah blah and they'll Say okay, this nurse has or this floor has 17 patients. We're going to, we're going to either call this nurse off because the ratios are tight. They always staff to tight.

Like they don't ever use the benefit of doubt like well we could get admissions overnight. They, they'll staff it to where like okay, we have one extra bed so suddenly the floor will get 345 admits. Maybe they can call the nurse in but they always will end up being a nurse over ratio.

Like they just always do that. They never. It's hard to frustrate.

No. And so this, like you said, there's this timetable 5am to 5pm so someone, a supervisor I assume hospital would make that determination on where to place certain nurses on a day to day basis, on a day to day need.

And they always do it on the side of what is the least amount of staff we can go with right now. And that's the way the staff. And it's at 5pm I work night shift in the ER. Our business time is from 3pm to midnight.

That's when we're slamming and if there's not enough, there's been times where zero, we don't have enough staffing for this floor. ICU is a perfect example. They don't ever go over ratio in icu so if they're short staffed there, they'll be like we don't have ICU beds.

So now we're holding patients down in the ER and you're, you know, any patient, a relative, whatever, that's the last place you want your family Member to be on ICU level care is in the ER because we have so much stuff going on. It's chaotic. Patients are more aggressive.

There's so much variables to add in to what the executives have been talking about. You can have five med surg patients but with the behaviors, the increasing behavior since COVID has skyrocketed, we've had to implement specialized programs on how to deal with violent and behavioral patients at our hospital because of the increase.

And one patient like that could take up a nurse's whole night of continuously addressing that. It doesn't matter if a mom comes in and she's been doing a prenatal vitamins and blah blah, blah.

And this other one is off the streets because it shouldn't matter if a patient is more healthy or not, that we're going to get more patients or not. We should have fixed ratios for each floor. It is safe. It helps us set up our night. We're not overstressed. You Know, it's a lot guys.

Okay. And I think I want to be fair, I was asking, hah. All these different questions about the different units. You mentioned telemetry and med surg. I again have no idea what that is. Can you explain to this Committee and for the public who maybe don't have that knowledge, what is that?

So telemetry patients are patients that are admitted for various reasons but where we are monitoring their cardiac status continuously. So they'll be on a monitor whether it's remote or wired in. Typically they can be more higher acuity, but they can also be a surgical patient that just has a history of something that they're not specifically there for.

MedSurg are your typical medical surgical patients. They come in for infections, they come in for wounds, they come in for a whole variety of things and patients can always move throughout. So a patient can come in originally as a med surg patient, be upgraded to telemetry or ICU or progressive care.

And so it's a very fluid kind of situation. Or it can be very fluid.

Okay.

One thing I would like to say, I hear everybody talking about, you know, yeah, it's, it's hard, you know, we post these positions. It's really hard to get nurses that want, you know, that can work or to get nurses that are qualified. There's plenty of qualified nurses in this state.

There's not as many nurses that are willing to work in these conditions in this state. So by having these ratios, you will very well could be bringing back a lot of experienced nurses to the bedside.

Actually, to follow up on that one, I like to call up HCH. The Hawaii State Centers for Nursing. If you guys are still here, can.

I just say real quick, I have a 40 years experience as a med surg nurse. They've been gaslighting you guys. The ratios are the minimum we can buy. Ratios. I'm sorry, Sorry, we need to move on.

Thank you.

So Hawaii State Centers for Nursing, are they here in person or on zoom? Okay, I guess not. Well, I'm sorry, since they're not here, I'll just ask the follow up for you. I'm sorry, I didn't get your name.

Melissa Robinson with UNAC UHCP. I work at Maui Memorial.

So the 2023 report from the Hawaii Nurses workforce created by the Hawaii State Centers for Nursing says 97% of nurses who currently live in Hawaii already work in a nurse related job. This is again going to your point about qualified nurses being available.

That sounds like there's a lot of qualified nurses who are not working in hospitals right now. But based on this report, most nurses who are qualified and are able to work, are working.

So again, I don't understand where you think that we're going to be able to have this huge workforce surge of qualified nurses to fill these ratios if they are right, if hospitals currently are able to fill them, I guess the.

Question would be, are they working in the State of Hawaii? They may have a license and they may be working, but they may not be working here in Hawaii. So they're travel nurses. They left to pursue better working conditions, and we're just asking for better working conditions in Hawaii.

Okay. Okay. No, I'm sorry, Chair. No further questions.

Thank you. I'm sorry, we need to move on. Thank you. If there are no more questions, let's move to. Go ahead. Representative Amato.

Question for Hilton Raithel, please. Thank you for being here and testifying. My question is quite simple. So these nursing. These safe staffing ratios are baseline, correct?

That is correct, yes.

Would these baseline staffing ratios prevent you from assigning additional care to higher acuity patients? Would these safe staffing ratios somehow prevent you from ensuring that each patient receives the care that they need?

I think I'd need to defer to one of our hospitals because I don't actually work in a hospital. We represent the hospitals. So. Amy, can you.

Okay, sorry. Could you repeat the question?

Sure. Would these baseline staffing ratios prevent you from assigning additional care to the higher acuity patients that require more care? Would these ratios somehow tie your hands?

I think that what we've seen happen around this is really, it comes down to the accessibility to care.

And Joan alluded to this a little bit in terms of the wait times and the hold times in the emergency departments, which other people have mentioned, the holding that happens in the surgical areas and being able to have those numbers and meet those numbers.

I think the challenge that we have with this really stems around that cookie cutter approach, that this is a number for every unit in every hospital or organization across our state. And there's so much variation in the types and of care that we provide that we need to have that flexibility.

It is the cookie cutter approach, that one size fits all approach doesn't work. Patients aren't numbers, and so we can't apply the numbers.

Thank you. Thank. That's fine. Thank you.

Thank you. Members, if there are no other questions, let's move on to decision making. I know this is a very difficult decision for all of us, and first of all, I'd like to thank the nurses for being here, taking time off of their busy work schedules to be here.

And believe me, I have the highest respect for nurses. You were there when I was born. You were at the bedside of my parents when they passed away and I couldn't be there. So I hear you. I believe you when you say you're overworked and understaffed.

I also respect the statements we've heard from hospitals that, you know, they are understaffed because they hire as many qualified nurses as they can and there often times are not enough. As legislators, it's our responsibility for doing our share to produce more of a workforce.

This Committee alone either has or will be passing legislation to provide training for high school students to train as LPNs even while they are still in high school. We're increasing tax credits for preceptors who train our healthcare professionals.

And we're about to consider a loan forgiveness program that will produce more than 900 health professionals over the next two years. It takes time and we've heard how dynamic conditions are in hospitals and how difficult it is to legislate mandates for nurse staffing ratios under these conditions.

I also have a concern that when we hear that California hospitals consider closing units for lack of enough nurses, people in California can drive down the road. And we can probably do so in Oahu, too, to go to a different hospital, but not so on many neighbor islands where there may be only one health facility.

So for all those reasons, I'm going to defer this Bill. And I know it's unusual, but I'll ask Members for any comments if they have them.

Thank you, Chair Takayama, and thank you for your leadership and for hearing this Bill. And thank you to all the testifiers for coming today on this issue.

I think based off the testimony that I've heard and perhaps my line of amateurish questions regarding technical medical information, I think I've demonstrated that we don't, we're not qualified to the Legislature. We're, you know, we're not qualified to legislate ratios.

You know, having living with someone who is trying to get into the medical field, I understand the complexities of. No, I don't understand the complexities of medicine and much less the day to day Administration of a chaotic place like the hospital.

And so, you know, I do agree with Chair Takayama that we need to continue the work to grow our local workforce for nursing. I hope that we are able to make progress on this issue.

I don't necessarily believe that staffing ratios are the right way to do this, and I'm not convinced at the moment that we are qualified to administer this policy as a Legislator, as dlr, as an Administration.

So with that, you know, again, I'm sorry to everyone who came to support this measure, but, you know, we'll continue to do the work, try to support you guys, you know, in other fields.

Thank you, Vice Chair.

If not.

Okay. Members, any other questions? Comments? Representative.

Referring this bill, you know, I feel that this is a good Bill that we should look at. I lived in the hospital probably about four months in November 21st. I lost my wife to cancer.

And the battle and the challenge that these nurses face day to day, it's not about, I feel it's about the knowledge that we have. It's the common sense that the overwork, the working so much hours.

And I get to say that I was blessed to have great nurses at her bedside, to take her home and to work on her. And it wasn't just her, was many other patients that they worked on, but they gave great manners.

And it's not about just only the great manners, but to know that these nurses had actually worked all the way through with almost no break even at 24 hours. They see them at night, they're working on other patients. I really do think that the nurses need the support and the help.

And I'm not saying that we needed to be educated so much on them, but to understand that they overworked and been really putting great love to the patients out there.

So thank you. Thank you for your comments, Representative Amado, followed by Representative Kong.

Thank you. Chair, brief comment. As a once high acuity patient that spent quite a bit of time in telemetry Ward after an extended stay in the icu, I experienced firsthand from the inside, from the patient's perspective, the burnout that our nurses experience.

You know, I feel that it falls upon the Legislature when the unions are unable and hospital leadership are unwilling to act at the bargaining bar, bargaining table to address the needs of our nurses. I'm disappointed this Bill is being deferred, but I respect your decision. Chair. Thank you.

Representative. Any others? zero, please follow up.

Yeah, and, and thank you to everyone who testified today. For me, it's a lot of mechanics. And what I heard loud and clear was DLIR is not equipped. And my concern is we have a lot of programs that our chair mentioned that is really moving the needle as far as loan forgiveness programs and growing that workforce.

We're going to be having to make a lot of tough decisions because of the number of federal mandates that are coming down from our federal Administration. And if DLIR is tasked with this and they don't have the staffing, we're going to have to divert funds from other areas.

And I really want to see our loan forgiveness program move forward. I want to see us grow that workforce so that we can begin to keep our kids home. I have two Members who are nurses, and I understand the burnout. I hear it when they come home.

I would love to see some of the work in the staffing council to look at. What was very clearly articulated was the demoralizing impacts of the overworked care that they provide for their patients.

And if there are spaces within that staffing council when we can start to give our own nurses some relief and debriefing for the mental pressures that they have, I think that's another area where we can work hard at. Thank you, Chair.

Thank you, everyone. We're going to adjourn this Joint Hearing and I'm going to ask health members too. Garcia, please.

I just wanted to say that it. Is quite disappointing that the bill is being deferred regardless of people's support or opposition. I think this conversation was worthy of moving forward. There are two more committees that it. Could go to to have this conversation. So not happy about it, but thank you.

Thank you. We're about to join this joint command.

Sorry.

I wanted to agree with Rep. Amato when she talked about that when bargaining doesn't work, we have legislated a number of things. And what was important is that I was a unit Member also for many years.

But for something like the nurses, when we're talking about their bargaining, we're not talking about their pay that they're taking home in their bank account going home. We're talking about any one of us who could end up on those beds with them helping us.

And so that's something different when we're just, we're not talking about their vacation days or things like that, we're not getting involved in those things. But I also want to mention, as I heard here, that, you know, we may not be qualified to legislate these things.

But I would also have to say that I think that there's many things that we've legislated in the past, probably in the future that we may not, as individuals be qualified to do. And I hope that in the future we take the bold step to bring something like this back up. Thank you.

Thank you. This Joint Committee is adjourned. We're going to reconvene as the Health Committee in one minute. So I'm going to ask Health Committee Members to stand by. Thank you.

Thank you very much for convening the Committee on Health on our 9:30 agenda, slightly delayed. Thank you, Members.

As I've advised you, we're going to take up our first two bills, which are triple referrals, in an expeditious manner, I hope, and then have decision making on those first two bills to enable our Staff Attorney to begin writing the Committee report, which is due this afternoon. So we'll begin with House Bill 1427 relating to Avian influenza.

And first up we have Department of Health in support. Let's see. Department of Land and Natural Resources. Okay.

Aloha. Chair. Vice Chair. Members of the Committee, I'm Afshin Siddiqui with DLNR and I am here to support the measure and happy to answer any questions.

Thank you. Department of Agriculture in support. Hawaii State Health Planning and Development Agency, Shipta. Jack Lewin and support on zoom. Hawaii Food Industry Association, Lauren Zirbel. Not present, but in support. Hawaii Cattlemen's Council in support on Zoom. Not present. Anyone else here wishing to testify In House Bill 1427, please step forward. Seeing none. Members, any questions?

Seeing none. Let's move on to next bill, which is House Bill 1300 relating to a cancer center, cancer study to be performed by the, UH Cancer Center. Office of Hawaiian Affairs in support. Lani Park, UH System.

Hi, members of the committee, my name is Lani Park. I'm a researcher at the University of Hawaii Cancer center and I am in support and I am here for any questions you may have.

Thank you. Quick question while you're up there. What would be the estimated cost of such a report?

It would be for a two year study at 500,000 per year. So 1 million total.

500,000 per year for each of the next two years. Okay, thank you very much. Queen's Health System?

Chair, we'll stand on our written testimony.

Thank you. American Cancer Society, Cynthia Au. In support.

Thank you, chair and committee members. This year, 9,000 people in Hawaii will hear the words, "you have cancer." That is an uptick of diagnoses since last year.

Collecting data on the social determinants of environmental factors of the populations of Native Hawaiians, Pacific Islanders, and Asian groups, including Filipinos, will help to provide much needed information on why these groups have cancer rates in Hawaii. Thank you for hearing this important bill. I apologize. Cynthia Au, American Cancer Society, Cancer Action Network. And we support this bill. Thank you.

Thank you very much. Anyone else wishing to testify on House Bill 1300? Please, let's see. Iron, Iron workers. Yeah. I'm sorry I missed you.

You lost it, huh? Thank you. Good morning, chairs and vice chairs.

Cliff Laboy.

My name is Cliff Laboy. Oh, you set off the alarm. I'm with the...

Please, proceed.

I'm with the Iron Workers Stabilized Fund. Here on behalf of our manager, George T. Paris. We are totally in support of this bill. We just want to bring up couple pieces of information regarding this.

Investigating the impact of environmental factors, particularly for the individuals living near landfills in Nanakuli is critical. A study conducted by the federal government labeled 2010-2015 Center for Disease Control Small Area Life Expectancies Study found that residents in this area had a life expectancy of 10 years lower than the state average.

The Waianae Coast communities in general experience disproportionated high rates of certain cancers and other chronic disease underscoring the urgent need for its research. This study would not only benefit the Waianae community, but also inform interventions for other communities facing similar environmental challenges. The Center for Controlled Disease did this study back in 2017.

So I don't know if you guys have it or?

Can you provide that to our Committee Clerk and put that in the...

I have one of these for each of you. I will hand it over.

Thank you.

So we again, we strongly support this bill. Thank you very much.

Thank you, Mr. Laboy. Go governors. Anyone else wishing to testify on HB 1300? If not, let's move on to decision making, if you will.

On the first bill, HB 1427 relating to avian flu, Terra's recommendation is we adopt small amendment on page two suggested by Department of Health on lines seven to nine, making clear that the testing includes humans and wastewater and its potential impacts on human health at a defective date.

The blank appropriation is already in the Bill in the report. Language will suggest, should other committees consider this, that the Department of Health is requesting between 3.3 million to 4.7 million, depending on the availability of federal funds. And Department of Ag is requesting $293,000. Members, any questions, comments or concerns, if not Vice Chair for the vote.

[Roll call]

Thank you. House Bill 1300 going to add a defective date as well as blank amount for. Well, it contains a blank amount for funding. Put in the report language that the suggested amount for such a study is recommended at $500,000 in each of the next two years. And I said defective date.

So any questions, comments or concerns if not Vice Chair for the vote.

Thank you, Chair. Members voting on House Bill 1300. Chair's recommendation is to pass with amendments noting all Members present. Any Members voting no. Any Members voting with reservation. Chair, your recommendation is adopted.

Thank you, Members. I appreciate your attendance and forbearance. So we'll resume the 9:30 hearing with HB213 relating to loan repayment for healthcare professionals. And first up, we have Will Kane, Office of the Governor in support. Department of Health Department stand on its testimony in strong support. Thank you, Shipta. Dr. Jack Lewin in support. Uh, System Jabson.

I'm sorry, uh, system. Lee Buenkense, Chair, Vice Chair.

Committee Members, Dr. Withey and I are here on behalf of uh, system. We stands in strong support and are happy to take any questions. Thank you.

Thank you. Queen's Health System. Chair will stand on our testimony. Strong support. Thank you. Kaiser Permanente Jonathan Ching. Morning, Chair. We're standing. Thank you.

I'll just add that this is something that, you know, over the past few years, there's tangible benefits that we're already seeing continue appropriation for this will get.

You know, there's a huge wait list. Thank you. Aloha. Keir. Mike Nguyen on Zoom. Not present in. I'm sorry. Here in person. Yes. Sorry. I'm used to seeing you on Zoom. You look different. Sorry. Rachel Wilkinson, Hawaii Association of Health Plans and so support. Anyone else I missed who wishing wishes to testify on. Please identify yourself.

Chair. Vice Chair. Richmond Lazar, testifying for Hawaii Dental Association. We stand on our written testimony and support. I would just add that there are no dental schools in Hawaii. So anybody who's an aspiring dentist in Hawaii has to fly to the mainland. And, you know, without. Without incentives to.

To help improve the workforce, they might stay there rather than coming back here. So thank you.

Understood. Thank you. Last call. Anyone else? HB 213, if not Members. Any questions? Seeing none. Let's move on. House Bill 474, Falls Prevention Department of Health.

The Department appreciates the intent of the measure.

I'm sorry, can you please step forward and. We can't. People have to hear you on the mic.

Hi. Robert Law from EMS IPSB. The Department appreciates the intent of this measure and stands by its written testimony.

Okay. Executive Office on Aging in support. Let's see. AARP in support. Anyone else I missed who wishes to testify on HB7 474? Seeing none. Let's move on. HB 729. Marriage of minors. Minors with a. Or not. ER. First off, we have Attorney General.

Good morning, Chair Takayama and members of the committee. I'm Deputy Attorney General, Erin Torres. The department submitted written testimony providing comments.

If this committee chooses to pass this bill, we recommend repealing HRS chapter 560, article 5, section 208 B5 of the Uniform Probate Code because that section currently empowers a guardian of a minor to consent to the marriage of that minor. Thank you.

I'm sorry, while you're up there, can I ask a quick question? There's also an exemption for sex assault of a minor if the perpetrator is married to that minor. Should we also repeal that section?

I'm not aware.

You can think about it. We have more testimony so you can come up.

Do you have that section that you're referring to?

It would be section 707-730, subsection 1, subsection C, ii. Okay, so you can look that up. We'll continue with the testimony.

Thank you.

Department of Health?

Department will stand on its testimony offer.

Thank you. Hawaii State Commission on the Status of Women.

Hi, Llasmin Chaine. I stand on written testimony.

Hi, thank you very much. On Zoom, I think we have Fraidy Reiss, Unchained At Last. Please, proceed.

Hi. Thank you, chair. This is a really important bill. I urge all of you to vote yes on HB 729 so we can end child marriage in Hawaii. Right now, parents can enter a 16 or 17 year old into marriage with nothing more than a signature on a form. And there is no input required from the teen.

There is no recourse for a teen who doesn't want to marry. I'm with Unchained At Last, a survivor led nonprofit organization working to end forced and child marriage in the United States. We provide direct services and we have worked with teens who showed up sobbing at the clerk's office begging for help. There's nothing the clerk, the girl or anyone can do to stop that marriage.

Thank you.

And keep in mind, when someone is forced to marry, their own parent almost always plays a crucial role in facilitating it. And then the current law also allows parents to enter a 15 year old into marriage if they also get judicial approval. And at first glance you might think, okay, well, judicial approval, there's a judge involved.

It's got to be better than just a signature on a form. But here's the thing. The judge is not even required to interview that 15 year old. So there is still no input from the teen. No recourse for a teen who doesn't want to marry.

And the judge is not even required to consider any specific criteria other than, I guess the fact that the minor resides in the court's jurisdiction. Now you'll hear about all the harms of child marriage.

But just one thing that I want to say quickly is that the current law is encouraging and legalizing the trafficking of minors under the guise of marriage. And this is because of a loophole in federal law. The federal government doesn't specify a minimum age for spousal or fiance visas.

Instead it defers to state, state law in the relevant state where the couple will reside. Well, Hawaii's state law right now says 15 year olds and 16 and 17 year olds can legally be entered into marriage.

Which means that right now 15,16, and 17 year old girls living in Hawaii can legally be trafficked for their citizenship, forced to marry adult men overseas so that the men get a visa and a path to citizenship. And the reverse is true as well.

Men in Hawaii can legally import child brides of age 15,16, or 17 from anywhere around the world. Legally sex traffic them to Hawaii under the guise of marriage. And this is not a small problem. The U.S. Senate

Summarize your testimony please. Thank you.

Yes, so just, just to summarize, the U.S. Senate Homeland Security Committee has shown that this issued a report recently showing thousands of minors are being trafficked under the guise of marriage. So I urge you to make the marriage age 18, no exceptions, to close that legal loop of the last trafficking of minors.

Becca Powell, Unchained At Last. Becca Powell.

Good morning, my name is Becca Powell, I'm the Director of Advocacy and Outreach for Unchained At Last. I'm here to testify in strong support of HB 729. In addition to everything you just heard, another reason why the current law is dangerous is that minors are automatically emancipated upon marriage, which is really dangerous public policy.

It ends their parents financial obligation to the minor, regardless of the minor's own level of financial Independence. Normally, in order for a minor to emancipate, they need to prove to the court that they can manage their own financial affairs.

But no one looks at that when we just automatically emancipate minors because their parents decided it was time for them to get married. And this can cause that minor to become financially dependent on their spouse, which is a huge risk factor for domestic violence.

It's one of the main reasons why domestic violence survivors have cited for staying in abusive relationships. But also it can lead to teen homelessness because 70 to 80% of marriages before 18 end in divorce. So if that minor is financially turned on their spouse and that marriage likely ends, where's that minor supposed to go?

Unfortunately, we've seen some of them end up on the street. And another reason why the law is dangerous is that it allows already emancipated minors to marry. Emancipation is intended to give minors who can't be reunited with their families some limited rights of adulthood so they can navigate the world independently until they turn 18 and get the full rights of adulthood.

However, emancipated minors aren't allowed to engage in activities that are unsafe or inappropriate for their age and are not necessary for their independence, such as buying alcohol, cigarettes, or tobacco. Given the many harms of child marriage, which as you'll soon hear, is considered a human rights abuse by the U.S.

State Department, and given that a minor doesn't need the right to marry to navigate the world on their own, emancipated minors also should not have the right to marry. And also the emancipation loophole opens up the terrible possibility the minor could be forced to emancipate so they can be forced to marry.

We have allies overseas who have reported seeing something similar happening in the United Kingdom in recent years, including parents setting up their child with a fake job at a family business and a fake bank account, so the courts believe the minor has their own lawful income and assets.

And emancipated minors only have some limited rights of adulthood and can still be trapped in unwanted marriage. In our experience, domestic violence shelters will turn away even emancipated minors. And emancipated minors often have a difficult time accessing the rights they do have.

Imagine, for example, how a landlord would feel renting an apartment to a 17 year old, even one who's emancipated. And you'll soon hear about the devastating lifelong repercussions that marriage before18 has on nearly every aspect of a minor's life. And unfortunately, these negative impacts don't go away just because the minor is emancipated. Thank you for your time. I'm happy to answer any questions.

I'm going to ask you to. Okay, thank you. ZONTA International Club of Hilo, Barbara Hastings, in support. Michele Hanash, AHA foundation, not present.

Here. Present.

I'm sorry, please proceed.

Thank you, chair and distinguished committee members. I am Michele Hanash, Director of Policy and Women's Programs at AHA Foundation. We are survivor founded nonprofit, working to enforce in child marriage, including by supporting survivors and at risk individuals to find safety and services. You've already heard many reasons why child marriage is dangerous.

Another is that it undermines Hawaii's statutory rape laws. So typically an adult 20 or older who has sex with a 15 year old can be charged with sexual assault, but not if they are married to each other. And the data shows this has actually happened in some cases. Statutory rape laws prevent adults from sexually abusing children.

But for these minors, their spouses instead received a get out of jail free card for statutory rape. We cannot be complicit in child rape. And the solution is not to set a spousal age difference.

While in general, a large age difference might be more likely to signify coercive sex, limiting spousal age difference does nothing to address the main power imbalance most commonly present in child marriage. That between the child and the parent, forcing them to marry.

Most survivors we have worked with were forced to marry by their parents, regardless if their intended spouse was close to their age or decades older, and regardless if they were being forced to marry their own rapist.

A limitation of spousal age difference also does nothing to mitigate the many harms caused by child marriage you will hear about, like loss of education, reproductive rights, financial hardship. And I wish I could say this wasn't happening in Hawaii, but unfortunately we know it is. 835 minors were married between 2000 and 2022 in Hawaii.

82% were girls wed to adult men in average four years older. So while child marriage harms all children, you can see it disproportionately harms girls.

And around the globe, survivors are leading a movement to end this harmful practice that leaves girls vulnerable to sexual exploitation and servitude. Seeing the harms caused to their girls and wanting better outcomes for them, 193 countries have agreed to the goal of eliminating child marriage by 2030.

And just in 2024, for example, Sierra Leone and Colombia have both ended child marriage and joined the ranks of those working to ensure their girls have bright futures. So in conclusion, if we value our girls, our laws should reflect that. And we must ensure they keep them safe from exploitation, abuse, and trafficking, and don't encourage it. And that is why I urge you to vote yes on HB 729.

Thank you. Sara Tasneem on Zoom.

Yeah.

Please, proceed.

Yeah. Aloha. I am here today testifying in strong support of HB 729. My name is Sara Tasneem, and as a survivor of forced child marriage, I'm here to share my story to highlight the very real harms that minors face when forced into marriages that they cannot easily escape from.

At the age of 15, during a summer visit to see my dad, I was forced into a marriage I did not want. My father introduced me to a husband, to my husband to be one morning and I was told that I would marry him that night.

That man was 13 years older than me and I had met him for the first time that morning. He was 28 years old and I was 15. My mom did not know that this was taking place, even though she thought I was just going to come home after my summer visit.

After a short spiritual wedding that evening, I was handed over to my new husband and left in his care. I lost all of my rights that night. I lost my reproductive rights, my childhood, my education, my freedom. And I lost myself that night. I would never be the same person again.

I was not allowed to go back to school. Instead, I was raped daily and impregnated almost immediately. Six months after our spiritual ceremony and being left in the care of my abuser, I was legally married at the age of 16 and pregnant to my rapist.

My pregnant belly should have alerted authorities instead of rubber stamping my marriage certificate and locking me into a marriage that I could not leave. As a minor, I faced extreme and numerous barriers to being able to leave my abusive marriage. I was not able to escape to a domestic violence shelter because I would have been turned away as a minor.

I was not able to hire an attorney because as a minor, that contract would be null and void. I was not even allowed to drive because I hadn't learned how and I was being controlled by my abuser. Sadly, I am not the exception.

Minors do have limited rights and they do not share the same rights as an adult. It has taken me years to address the severe impact child marriage has had on me. And I don't imagine that I'll ever become whole.

Thank you. I'm going to ask you to summarize, please, Ms. Tasneem.

Sure. In summary, thank you for hearing my testimony today. I am here on behalf of myself and on behalf of many of the survivors who have had their voices stolen from them. Thank you for hearing my testimony.

Thank you. Any other testifiers on HB 729? Seeing none, attorney general, Do you have any. I'm sorry, did I. Is there someone on Zoom?

Yes, sir. Hi.

I'm sorry. Please identify yourself and proceed.

Yes, my name is Andre D. Fields. I work with Unchained At Last. Good morning, chair, vice chair and members of the committee. My name is Andre Fields and I work on the advocacy team at Unchained At Last. I'm here to speak today in strong support of HB 729.

We all understand that turning 18 doesn't suddenly grant someone wisdom or maturity. But what it does grant, what it must grant, are the full rights of adulthood. And for someone being forced into marriage, those rights are not just a formality, they're a lifeline.

Marriage before 18 creates what has been called the Kafkaesque nightmare, where young people, no matter how mature, are legally powerless to protect themselves. Leaving home before 18 is often a status offense and if a minor somehow escapes, where would they go? Domestic violence shelters routinely turn them away. Youth shelters can't provide confidentiality.

They are required to notify parents or guardians, potentially sending a child back into harm's way. Even securing legal help is nearly impossible because contracts with minors, including retainer agreements, are voidable.

And to add insult to injury, minors can't even bring a legal action in their own name to stop a forced marriage, including filing a protective order against parents who are forcing them to marry. Some might argue that marriage itself grants emancipation, but the so called freedom comes too late.

By the time a child is emancipated through marriage, they have already endured the trauma. And even then, the barriers don't magically disappear. Emancipated minors still struggle to find safe housing, economic opportunities, and protection from abuse. The United Nations Office of the High Commission for Human Rights makes it clear, all marriages are by definition forced marriages.

The consequences are devastating and lifelong. Child marriages destroys futures. It rips young people from their education, trapping them in cycles of poverty. It strips away their reproductive and sexual rights, forcing them, forcing many into unwanted pregnancies. It puts them at an increased risk of domestic and sexual violence. And when young people reach out for help and learn of their limited legal options, we have seen some turn to self harm and even suicide attempts.

Mr. Fields, I'm going to ask you to please summarize. Please wrap it up.

Yes, the U.S. State Department calls child marriage a human rights abuse. We must call it what it is, a failure for our laws to protect the most vulnerable amongst us, and we must act.

Raising the marriage age to 18 with no exceptions is the only way to close the dangerous loopholes and ensure that every young person has the full rights and protections of adulthood before they are thrust into marriage. For these reasons, I implore this committee to give its favorable consent to this legislation. Thank you so much.

Thank you. Any other testifiers on HB 729. Seeing none. Members, any questions? Attorney General, do you have an answer on?

I apologize because I'm going to have to qualify my answer. I don't practice criminal law and I did not clearly did not pass this through my superiors at the AG's office.

But upon reviewing the section that you identified, I do believe it clear, speaking in a personal capacity, I do believe it's clear that that would have to be repealed as well.

Thank you so much. No other questions? Let's move on to HB 341. And for the testifiers, I might ask, you know, we have your written statements. We are in a little bit of a time crunch because we have to finish these bills before session starts, before noon. So if we don't finish up, they all die. So let's move on to HB 341, special purpose revenue bonds for the Big Island. And first up we have Hawaii Island Community Health Center. Richard. Oh, I'm sorry. Please.

Aloha, Chair, Vice Chair. My name is Natasha Ala, and I'm here on behalf of Richard Taaffe, our CEO. He's in Washington D.C. right now advocating for healthcare. And we want you to vote in favor of our special revenue bond here today. It will allow us to build, expand our footprint of primary health care services, medical, dental, behavioral health on the Big Island in the districts of Puna, Hilo, North Kona, South Kona, and Ka'u. It'll allow us to expand to additional 32 primary care exam rooms and would be able to serve an additional 15,000 patients.

So right now we're seeing 40,000 patients, and then we would up that to 55,000 patients, which would be essentially one in three residents on the Big Island we'd be able to serve. And right now 60% of our patients are Medicaid recipients, and we are the safety net health care organization for primary care on the Big Island. And I'd be happy to answer any questions you have.

Thank you so much. Mike Nguyen, AlohaCare. No, not at all. In support. Let's see. We also have written comments from Department of Budget and Finance and supportive comments from Hawaii Primary Care Association. Anyone I missed wishing to testify on HB... Please step forward.

Chair, Vice Chair, Committee Members. Kika Bukoski testifying on my in my personal capacity. Real quick. I know you guys got a lot of bills to hear before session, but the neighbor islands have a critical acute care need. And my understanding this is for primary care, but if I'm correct, if we can help with primary care to prevent people from getting into situations which require acute care, it might help alleviate some of the capacity concerns on neighbor islands. But I do want to highlight and strongly support this measure, but highlight the critical needs on the neighbor islands for both primary and acute care. Thank you, Chair.

Thank you, Kika. Last call HB341 Members. Any questions? Seeing none. Let's move on. House Bill 784 calling for a new ambulance on the Big Island. Department of Health, good morning.

Robert Lau from EMS IPSB. While services to our outer island locations are extremely important, we need to take a look at the whole picture in terms of service delivery.

What's happening in rural areas is we have demand for EMS services, but they are significantly lower than normal cities like Honolulu compared to or even Hilo compared to like Makalei in this proposal. So what's happening is we're trying to avoid a situation where we install a new ambulance and the call volume is relatively low. Right. It's happened.

And we have some ambulance units that respond twice a day.

In lieu of that, what we're proposing is some amendments and go forward with a community paramedicine mobile integrated health model where the contractor or the provider is responsible for four ALS calls a day and the remainder they can do community paramedicine mobile integrated health to deliver various services under this model.

You know, it feeds into a bunch of different services that we all been listening to this morning. And we'll hear later this afternoon that that is it.

Thank you. Thank you so much. Let's see. Anyone? I have written comments from Oha, Hawaii Health Systems, Hawaii County Council, Hawaii Fire Department, all in support. Anyone else I missed who wishes to testify and HB 784. Okay, seeing none. Let's move on to HB 715 relating to a certificate for stillbirth. First we have.

First we have Department of Health.

Good morning, Chair Takayama and Committee Members. Lorrin Kim, Department of Health, Policy and Planning Officer. I apologize for the late testimony. We are offering comments and want to highlight several very important concepts. We certainly empathize with loss of pregnancy, but it is a best practice in vital records to not issue a death certificate for a person or a fetus who does not have a birth certificate. The major issue here is a certificate of stillbirth must not have any legal standing.

And we are offering to do a commemorative certificate memorializing the loss of a child, of a pregnancy, as long as it has no legal standing. And we would also request the option of a fee. I would also like to call your attention to Planned Parenthood's testimony on unintended consequences of legal standing for stillbirth, which implies life beginning at conception, and that conflicts with state law and the best practices of vital records.

So a certificate of fetal death is issued if a baby expires prior to their birth and they do not take one breath. If they are delivered and take one breath and are expired, they will get a birth certificate and a death certificate. So there are many implications to this that I think the Committee should take very seriously that may impact reproductive freedom and reproductive rights.

That said, the Department is willing, if you authorize us, to collect a fee because this does take time and energy from staff who are processing requests for birth, death, and marriage certificates in exchange for a fee to issue a commemorative stillborn certificate that conspicuously says, and is conspicuously backed up by law, that it has no legal standing. Very important. I'm available for questions. And again, I apologize for the late testimony for such a complicated issue. Thank you.

Thank you very much. On Zoom, I believe we have Malia Nobrega-Olivera. Please proceed.

Aloha kakou. Mahalo, Chair, Vice Chair, and Members of the Committee. I'm Malia Nobrega-Olivera, and I'm here with my husband, Victor Nobrega-Olivera. We're actually from Kauai, but tuning in today from San Francisco. We're parents of our baby, Kaʻaiʻōhelo, a stillborn that was born on June 8, 2015. Since then, we've been working with other parents and we've been working with our community and the Association of Hawaiian Civic Clubs, who has supported a resolution back in 2017, and then we brought it forward a number of years.

Just in summary, because I know that there's a lot on the agenda today, as a respect for parents like myself who have given birth to the baby after carrying baby for 36 weeks. This allows us to honor that birthing that we did, like every other parent, that birthing that brought baby Kaʻaiʻōhelo into my arms.

And unlike other parents, we did not leave the hospital with our baby. We've noticed, and you'll see in the Association of Hawaiian Civic Clubs testimony, that by doing our research, we've learned over the years that we are one of only three states that are not is doing what we're asking in this bill. And so we'll stop there and we'll be available for any questions. But mahalo ā nui for hearing our leo and our voice today. Aloha.

Thank you. Anyone else wishing to testify on House Bill 715? Seeing none, let's move on. Next bill is HB 36 relating to excited delirium. Department of Health?

Aloha, chair, vice chair, Lorrin Kim, Department of Health. We are offering comments and some amendments that we think will make the intent of this measure more effective. I would like to highlight the department has a ministerial role in documenting causes of death. We do not examine the body. We do not have the expertise.

We just document. The entities that do determine cause of death are upstream from the Department of Health from a vital records perspective. Coroners, medical examiners, and physicians. We recommend that chapter. The proposed amendments to Chapter 338 be taken out of the bill.

And we propose that a prohibition on excited delirium as a cause of death be placed in Chapter 327 HRS. Which is titled Death. It just says Death and there's 327c-1 is a section with the title of determination of death.

So we think that's a more appropriate place to put a prohibition for medical examiners, coroners, and attending physicians to not use excited delirium as a cause of death. Thank you. And I'm available for questions.

Thank you. We have a couple test fires on Zoom and again, I can ask testifiers. Remember, we do have your written testimony, but. And we are running short on time. But please proceed. Hawaii Disability Rights Center.

Yes, thank you. Real quick. Good morning, Chair Takayama, committee members. I'm Louis Erteschik. My testimony speaks for itself. I'm a lawyer, I'm not a Doctor. But I do know two things.

First of all, the obvious solution to these unfortunate situations is better training for the police in terms of de-escalation techniques so that they in particular so they understand how to interact with people with disabilities. Second, it's clear to me when we signed on to the amicus brief that's referenced in the other testimony.

But it's clear to me that this concept has been abused and misused all over the country to as a just, as an excuse for police misconduct. So I think the bill merits a lot of consideration, representative. And I hope the committee will, will keep it going and have some more discussions this session to see whether this belongs in our criminal system or not. So thank you.

Thank you, Julia Sherwin, Haddad and Sherwin.

Yes. Aloha. Thank you, Chair Takayama, for introducing this bill. I've been a civil rights lawyer for 30 years. I coauthored the Physicians for Human Rights report on excited delirium. I strongly support HB 36 and I did submit written testimony that I ask you all to review given our short time today.

But basically, excited delirium is junk science rooted in racism and sexism and bankrolled by the manufacturer of tasers. Hawaii's own Sheldon Haleck was a victim of this junk science theory. Next, and that's discussed in my written testimony and will be discussed by Sheldon's mother, next month Sheldon's ohana will observe the 10 year anniversary of his death.

His death and the lifelong heartache for his loved ones were completely preventable and avoidable. You have the power at this time to make this pono to prevent further tragedies like Sheldon and his ohana have suffered. And your passage of HB 36 will send a message that Sheldon's death was not in vain. I'm happy to answer any questions. I've been working on this issue for 20 of my 30 years as a civil rights lawyer. Mahalo Nui loa for your time.

ACLU of Hawaii.

Good morning, Committee Members. My name is Wookie Kim. I'm with ACLU of Hawaii and we support HB 36. Sheldon Haleck, George Floyd, Daniel Prude, Elijah McClain, Tyre Nichols, Angelo Quinto, Adam Trammell. Each was killed by police. And to justify tasering, choking, pinning, kneeling on, crushing, handcuffing, pepper spraying, drugging, baton striking, beating, and kicking each of these individuals, officers used the same excuse, "I thought he had excited delirium."

Our written testimony elaborates on this point. But in short, as others have already testified today, excited delirium is not a real medical diagnosis. It's junk science and it's been weaponized to excuse police violence.

Especially against people of color and people experiencing mental health crises. And you'll hear from the family very soon, but here in Hawaii, right, It excused the death of Sheldon Haleck. An Air National Guard veteran who served our country. He was unarmed, nonviolent, and in crisis right outside Iolani Palace.

And police tased him three times, pepper sprayed him 12 times, hogtied him, pressed a knee to his neck, and he died. So you have the opportunity now to make sure that no other families, such as the Haleck family suffer what they've suffered. Because what happened at the trial, and I forgot to mention this in our written testimony.

The ACLU did submit an amicus brief in the Haleck family's appeal. But what happened at the trial was a travesty. Because three so called experts bankrolled by the company that makes tasers, were able to convince the jury that this so called syndrome, excited delirium syndrome, had killed their son and not police violence. In short, please pass HB 36. Thank you.