House Standing Committee on Health

Good morning, everyone. Welcome to this. First of all, welcome to the 30th day of the 2025 legislative session. Which means, depending on your perspective, we're either half done or we have half more to go. But in any case, it's been a pleasure. Committee on Health meeting today, Wednesday, March 12, at 9am in Conference Room 329.

With the indulgence of all the testifiers, we're going to take one Bill out of order, and that's SB 1494 relating to hearing aids. And we'll also have decision making on that as well. Because we do have a translator here for the assistance of the hearing impaired. So let's proceed with the testifiers.

Oh, and I forgot some housekeeping rules, which I'm sure most of you know already. We'll have testimony on zoom. For those on zoom, we ask you to keep yourselves muted and your video off while waiting to testify.

We do ask that all the test fires abide by a suggested two minute time limit to enable us to hear from everyone and complete our session before we have to go to a floor session. So let's begin with SB 1494. And first up we have the State of Hawaii Insurance Division.

Good morning.

Good morning. Chair Takayama. Vice Chair Keohokapu-Lee Loy. Jerry Bump, Acting Insurance Commissioner. We'll stand on our written testimony offering comments, and if you have any questions, we're ahead of it.

If I could the, the nut of your testimony is that this may be considered in need of an audit as a prospective essential benefit?

Actually, our concern was related to that, we're unsure if it will trigger defrayment provisions under the federal statutes.

Okay.

Yes. Yeah.

Okay. Thank you. Thank you. Next we have Jack Lewin, State Health Planning and Development Agency.

Good morning. Chair Takayama and Vice Chair Keohokapu-Lee Loy and Members. We certainly support this. We recognize the complexity here. There's also. There's uncertainty about some of the products on the market.

But we really want to support hearing augmentation for those who need it and look forward to working with you and the other parties to make sure that happens. Thank you.

Thank you very much. Let's see. Disability and Communication Access Board.

Hi, Good morning, Chair and Members. My name is Bryan Mick. I'm here on behalf of DCAB and our Executive Director, Kirby Shaw. We are in strong support of the space. It is from the Deaf-Blind Task Force. Several years we have been trying to get this passed into law.

We did submit written testimony and I just wanted to highlight one section. We pointed out in here that currently private health insurance plans usually provide at least partial coverage for eyeglasses to correct vision. The coverage for hearing aids remains inconsistent and insufficient. Hearing is an essential sense necessary for effective communication, daily functioning and overall quality of life.

And for individuals with hearing loss, access to hearing aids is crucial for their participation in social, educational and professional environments. So thank you for considering our position.

Thank you. Kaiser Permanente on zoom, please.

Good morning, Chair, Vice Chair, Committee Members, thank you for the opportunity to testify. Kaiser stands on its testimony requesting an amendment. Thank you.

I'm sorry, could you, since you've gone to all the trouble of being on zoom, just briefly summarize your testimony, please?

Oh, sure. If we could please request an amendment, Chair. Adding the national standard of medical necessity to the any coverage on the cost of the hearing aids, which is a standard practice for, you know, usually the mandates.

We request the medical necessity be added there to control. You know, Clinicians to have the one on one with the NEM patients for their specific needs. So we just ask for that to be added in there.

Also, the Bill does have some kind of vague reference to notification of policyholders of this optional coverage through any literature or correspondence that ensures sends to policyholders, including the annual notice.

So we ask that that that just be amended to just require the annual notification which was standard practice when we poly- when the insurer sends out the evidence of coverage to policyholders.

Okay, thank you very much. Thank you.

Thank you.

Hawaii Association of Health Plans. Rachel Wilkinson.

Good morning, Chair, Vice Chair, Members of the Committee, Rachel Wilkinson, on behalf of the Hawaii Association of Health Plans. And we're going to stand in our testimony providing comments.

Thank you again. Could you just briefly summarize your comments? And so for the benefit of Members who just arrived, we're taking SB 1494 out of order hearing aids because we do have a translator behind us.

So you have our testimony before you. Somehow some things that we just wanted to point out in terms of the Medicare plans, we are preempted by federal law. So we don't think that this measure may have the intended effect that it's trying to impact.

And then the other thing is we think that that for especially hearing aids, we need to look at medical necessity rather than a mandatory minimum cost.

Okay, thank you very much. Thank you. Last testifier we have is HMSA.

Good morning, Chair Takayama, Vice Chair Keohokapu-Lee Loy, Members of the Committee. Walden Au, on behalf of HMSA, we stand on our written testimony providing comments. And basically the main point is that we think that this may be subject for auditor study.

We believe in 2022, SCR61 did compel the State Auditor to provide a study, but we don't believe it was actually done. So thank you for your time and we'll be available for any questions.

Thank you. That's all the listed testifiers I have. Anyone else wishing to testify on SB 1494, on Zoom or in person? Seeing none. Members, any questions? Seeing none, we'll go to decision making.

As I said earlier on this Bill, in this Bill, as noted by several testifiers, there is a question of federal preemption and also the fact that an audit has not been done on this proposed mandated benefit. So I'm going to suggest we defer the Bill.

There is Senate Concurrent Resolution, SCR 151 that does specifically propose an audit on this, and I suggest we act on that rather than this Bill. So we're going to. My suggestion is that we defer the petition. Any comments or questions, Members? If not, thank you very much. We'll now move on to the regular agenda.

And first up, we have SB 1448 making an emergency appropriation for the state hospital. And we have, let's see, Department of Accounting and General Services Comptroller Keith Regan.

Or Good morning, Gordon. Gordon Wood, Department of Accounting General Services Public Works Administrator. On behalf of Mr. Regan, the Department stands on its written testimony in support of this bill.

State Department of Health Aloha Chair and Vice Chair. Members, I'm Mark Lynn Scott. I'm the hospital administrator at the Hawaii State Hospital. We stand on our written testimony, but are in full support of this EA.

Which improves the environment of care, in a sense, funding for cleaning and ongoing cleaning and actually make sure that a third party looks at the entire structure of the hospital. So thank you for hearing us today.

Thank you. That's all the testifiers we have on this measure. Anyone else I missed? Who, who wants to testify? If not questions? Members Vice Chair.

Thank you. Mr. Wood, if you don't mind coming forward. You know, this is an emergency appropriation and I know we're in the middle of an issue and I just want to make sure, if you could give us some assurances that some of the the challenges that we're seeing to make this emergency appropriation are being addressed.

I think my concern is this is a lot more money that was initially planned for this facility and if you could help give this Committee some assurances that you have a better handle on the fixes that are necessary.

Yeah, certainly we are getting a better handle on this every day. Okay. We do have a sort of plan for action on this. The most that I can say about that plan for action is that we continue to look at all avenues. Okay.

Part of this updated request for this emergency appropriation is to do a comprehensive study of the building. And it's a fair amount of money. It's 2.4 million. And you might say, well, that's a lot to spend on a study.

And the reason that it's so large is because we have to go in and we actually have to do some destructive testing. And when we do that, then we have to repair whatever we've destroyed and so forth. So the costs do add up on that.

But the whole focus on that third party comprehensive study is to make sure that we've identified as much as possible of the issues that we need to address in this building.

And then a follow up question. Part of this design build process was the third party review, along with a project manager that allowed for inspections. In this tranche of money, are we using those same checks and balances or are we seeking other evaluation and review?

Okay. It's an excellent question and I appreciate you asking it. We are not continuing to rely on those past processes. In fact, we are engaging in different processes moving forward.

Great. Thank you. Thank you for helping me with that.

If you could. Go ahead. Representative Marten I hope you're comfortable up there.

So should we be successful in litigation against the designer builder, would the cost of this study be something that we could recuperate?

That is part of the thinking as we move forward on this. Yes. Is the ability not, not just through litigation, but, but through some predecessor actions that we can take as well as is to recover the costs that. That we've put into this.

Thank you very much. Thank you.

Chair, I do have a question.

You know, as our listening audience might not be aware, the state hospital project was the subject of a Committee hearing that we conducted about two weeks ago. And in the course of the hearing, one of the suggestions, as mentioned by members, is that why haven't we sued?

Yes.

The contractor might note that the cost of the original project was 160 million and it was four years ago. And we're now being asked for an emergency appropriation of 10.6 million. Yes. What is the status of suing a lawsuit contractor?

It is, unfortunately, a long, drawn out process. Okay. We are in the midst of that process. We have made a demand of the design builder to Fund this $2.4 million study that we're talking about. They have refused that demand. Okay. And so that then becomes part of our record.

Moving forward, though, before we get to litigation, there are, as I say, there are some predecessor steps that we have to take as well.

Okay. Now, also at the hearing, it was suggested or mentioned by you, I think that eventually we'll have to conduct a larger project to replace the roof at a cost of, I thought, $20 million or so. That is. Is that not part of this emergency appropriation?

That is not part of this emergency appropriation. There is a separate cip. It's in the CIP budget at this point to do that work. And it wouldn't be that that entire 20 something $1.0 million, it would be a smaller subset of that to replace the roof.

There is other work that is included in that 20 some odd $1.0 million.

As well, which is to say that in addition to the 10.6 emergency. $10.6 million in emergency funding, more. This isn't the end, that there are what, 20 million plus more dollars that the Legislature will be asked for?

Is that's correct to my understanding today, yes.

Okay. Okay. Thank you very much. Let's move on. If there are no other questions, next Bill is SB 1432 relating to changes and changes to responsibilities of the Department of Health concerning patients, the County of Kalawao and the Kalaupapa settlement. And first up, we have Department of Land and Natural Resources. Not present. Department of Health.

Good morning. Chair, Vice Chair, Members of the Committee, Dr. Diana Felton, Hoy, Department of Health. The Department of Health stands on our written testimony in support of this bill, which helps to address DoH's statutory responsibilities that would go into effect a year after the passing of the last patient.

As many of you know, there are responsibilities there are directly related to patient care. And so this bill makes those changes that would impact when there are no longer patients. Happy to answer any questions. Thank you for hearing the bill.

Thank you very much. Department of Hawaiian Homelands.

Aloha Kakayaka, Chair, Vice Chair, Members of the Committee, Oriana Leao of the Department of Hawaiian Homelands. DH stands on its written testimony with comments. DH appreciates the intent of this measure. And as noted in our testimony, the land identified as TMK 610101 is Hawaiian Homelands.

As many of you are aware, any changes for land use and zoning of Hawaiian Homelands is subject to the the approval of the HOMS Commission as well as beneficiary consultation. And we simply suggest that that be noted in the measure. I'm available for questions. Mahalo.

Okay, thank you. State Disability and Communication Access Board. Kirby Shaw not present. Maui County Council Member Keani Rollins. Fernandez on Zoom? Not present. Degree, Vanderbilt. Kaohana O Kalaupapa.

Good morning, Chair Takayama, Vice Chair K Oho Kapu Lee Choi and Members of the House Committee on Health. My name is Degray Vanderbilt. We stand in support of this bill. I want to say thank you to the staffs of the various members who engaged me yesterday to explain the slight amendments that we suggested.

And basically 90% of this bill is just scratching out things that are obvious and the law that administers the Department of Health, all the things that won't be applicable when there's no more patients there. But then two other things were slid in there. This Kalaupapa State Historical Area. And then there was a.

A statement that Colorado county will. I mean, it was definite, will become part of Maui County. There's been no meaningful discussion on either of these, and it would be hard to consider passing a law like this where there's been no community discussion. So my.

For better or worse, I just put in a couple of amendments that said there may be a Kalaupapa State Historical. I substituted may for shall. And same with the Colorado County. Wherever it says shall, it may. And maybe that's not the appropriate way. Maybe they should just be taken out altogether, I don't know.

But 90% of the Bill is just striking out things. And so. And I. And basically there's been just a lot of concern about both of these expressed by a lot of people on Topside, Molokai and at Kalaupapa. And basically the concerns stem from the fact that there hasn't been any meaningful discussion. So. Thank you very much.

Thank you. Members, do we have. I'm sorry, is there anyone else wishing to testify on the measure before us? Seeing none.

Mr. Chair, before you did mention earlier that.

You had a statement from what you mentioned earlier, you have a. Yeah, testimony from one of the.

Gloria Marks, who is one of our board Mmmbers, and she's in Lehigh Hospital now, and she had sent in some testimony by fax and somewhere it got lost around the track.

Why don't you go ahead and read her statement?

So here, let me. Here, I can pass this.

And I want to thank Alicia for trying to help me out. I was buggered.

On the back of the. On the back of the letter is a picture of Gloria Marks, whose testimony it is, and two other board members that have passed away. Boogie Kahilihiwa, who's right here with me. He was President for 12 years. And then Pauline Chao, who just recently passed away. But this is Gloria Marks testimony.

Aloha Chair Takayama and Vice Chair K Oho Kapuli Choi and Members of The House Committee on Health. I am Gloria Marks, a resident of Kalaupapa now residing at Halemahalo in the Leahi Hospital. I am a Member of Kaohana o Kalaupapa Board of Directors. I have attached a picture which means a lot to me.

It shows the last three patient residents on the Ka' Ohana Board of Directors, Boogie Kahilihiwa, Pauline Chao and me both. Boogie, who is a past President of Ka Hana and Pauline recently passed away. I'm unable to attend your hearing on Senate Bill 1432, so I'm submitting my written testimony.

I hope that your Committee supports the amendments to this bill which have been approved by the Senate WHAM Committee, especially the ones that call for Ka' Ohana and a Topside community Molokai organization to be included as members of all government transition planning team that is developing the transition plan for the future management and operations of Kalaupapa when there is no longer a patient community there.

These amendments adopted by the Wham Committee are reasonable and present to highlight the fact that Kalahana has a congressional authority to operate at Kalaupapa, which was signed into law by President Barack Obama.

Kaohana is on the same level as the major Kalaupapa stakeholders, the other five entities, all government agencies that operate at Kalaupapa by authority given to them by federal or state statute. Yet the government agencies continue to dismiss Ka' Ohana despite the fact that our organization is one conceived and fostered by the patient residents of Kalaupapa.

Given this fact, Kaohana certainly must be at the table with government agencies at any future meetings where there is any discussion regarding the future management and operation of Kalaupapa and its legacy. Thank you for this opportunity to provide your Committee with my written testimony. Respectfully submitted. Gloria L. Marks, Ka Waihona Kalaupapa Board Member.

Thank you very much.

And thank you very much, Mr. Chair, for allowing us.

Thank you. I understand we have Maui Council Member Keani Rollins Fernandez on zoom. Please proceed.

Aloha. I'm. Oh, there. Okay. All right. Aloha. I heard a last call to testify, so I call on my degree. If I interrupted you. Aloha Takayama Vice Chair Keoha Kapu Liloi and honorable Committee Members. I am Maui County Council Member Keanu Rollins Fernandez, born and raised Molokai.

Mahalo for this opportunity to provide testimony on SB 1432 SD2, respectfully asking that you defer this measure. Mahalo to Dr. Felton and Department of Health for introducing this measure and for starting this important discussion. The Molokai Community and our county government have never had the opportunity to fully discuss all the implications related to this bill.

As DeGrey has just shared, this bill hands over Kuleana of Kalawao county to Maui County. Our county is asking you to defer this. It would be irresponsible to pass this without appropriate discussion and planning with the county that would take over Kuleana. So please defer this today.

Having more time to plan through the details would be much appreciated. Mahalo.

Thank you very much. Anyone else wishing to testify on SB 1432 in person or on zoom? If not Members questions? Seeing none. Department of Health, would you.

I just wanted to ask about your testimony because you are asking that we delete portions that refer to the Department of Health having a role in managing Kalapapa after the last patient has gone. Can you explain why you would not. You should not be a partner in this?

Sure. So the Department of Health does not see a significant role for itself in Kalaupapa after there are no longer patients there. From the beginning, the health agencies, whether it was the kingdom or the territory or the state, had have always been about taking care of the patients. And that remains our primary role there as well.

Over time we have transferred a lot of our responsibilities for the running of the area to the National Park Service. And we see when there are no longer patients there that the operations will continue via the National Park Service as outlined in their general management plan and has been sort of in place since the 80s.

And then of course the land use will be dependent on the landowners dhhl their beneficiary consultation. And Department of Health really sees its role ongoing as really just being related to long term environmental cleanups that it feels a Kuleana to continue even after we no longer have patients there.

And how many patients are there?

There are seven total patients. Currently four are living full time at Kalaupapa.

Okay, thank you very much. No other questions. Let's move on to SB 955 relating to fitness to proceed. And we have first up, the judiciary. State Judiciary. No? Offering comments. Deputy Attorney General, Tricia Nakamat.

Good morning chair, vice chair, members of the committee. Deputy Attorney General Tricia Nakamatsu appearing on behalf of the department.

The department does oppose this bill in part and supports in part we do support the efforts to increase the number of private examiners by increasing the payment and making the expectations and the duties of those examiners uniform so that there's level field for all the private examiners.

They all know exactly what is going to be expected of them as well as their counterparts, we have reason to believe that doing that alone would increase the number of examiners significantly.

With regards to other portions of the bill, we are specifically concerned about the proposal to decrease the number of fitness examiners on felony cases from three to one. And that's due to the inherent decrease in reliability when that results when consulting with only one examiner as opposed to three.

There may be differences in opinions, of course, different observations, different things that popped up in reports or in their interaction with the defendant, and then also the seriousness of the felony offenses themselves, both for the defendant and for the community.

We do understand that section 704402.2 of the HRS provides that the court in appropriate circumstances may appoint an additional examiner or examiners. However, we feel that that is meant to be more of an exceptional unusual circumstance, not a norm. So we don't feel that that would properly address the need for multiple three particular examiners.

In addition, if there is a proposal that the state would provide one examiner and then the parties each can provide their own examiners, that essentially is going to provide create more of a adversarial type of environment where it currently does not exist.

You don't want to create a battle of the experts right now the way it is with all three examiners being selected from the states list, they're generally all well regarded and equally weighted by the parties. So it's actually not that common for the contested hearing to be necessary.

If it becomes, as I said, a battle of the experts, there will be a foreseeable increase in the contested cases, possibly in every case.

With regards to, we are also concerned about the prospect of expanding the use of the so called expedited examination reports that's currently found in section 70440428 those to all crimes, those fit, those are actually not complete fitness examinations. As we noted in our testimony, actual fitness examinations are outlined in 704404 subsection 5.

And there's four specific things that are supposed to be included in those examination reports. And that helps the courts and the parties to assess whether that person is truly fit to proceed with trial. And this of course is a very, very important.

It's one of the cornerstones of our justice system, ensuring that somebody in fact understands and participate in the criminal charges being pursued against them. So as I was saying, of those four things, only one of them is actually covered by the so called expedited examination report.

So it really does not provide a sufficient basis for the court in many cases. We anticipate that it could possibly lead to more individuals being committed to the Hawaii State Hospital rather than less because of that lack of information and lack of reliability.

As I indicated, we do support increase the number of examiners by increasing the pay, making the expectations uniform. We also note that the Penal Code Review Committee is currently meeting and is working very hard. They have a subcommitee specifically dedicated to Chapter 704 and this all of these things are being considered by them.

So if the committee is inclined to defer the bill, that could also be a possibility as to allow the Penal Code Review Committee to continue its work. Thank you.

Thank you, Department of Health.

Aloha, chair, vice chair and committee members. The Department of Health supports this bill at least for the intent. We are requesting amendments to address some of the concerns that are constituents are having in terms of the number of examiners.

So we'd like to introduce the language that we have at least three examiners and allows each the judiciary to determine the appropriateness of that.

The end goal of this is really to reduce the amount of patients that are being sent to the state hospital as 704404 and in the last two years it's been a 20% increase year over year since this inception of the Act 26.

So we're trying to mitigate this so that we expedite the judiciary process as well as support the decrease in people coming to the state hospital appropriately. And it still offers if the attending psychiatrist wishes to present their opinion to the court, they may do that. Thank you for listening.

Thank you. Office of the Public Defender.

And good morning chair, vice chair and members of the committee. My name is William Bento and I'm representing the Office of the Public Defender. You know, it's a unique situation when if you had a chance to review the testimony of our office, the Attorney General's Office, the judiciary, we're all saying basically the same thing.

And the reason for that is we work in the system every single day and we deal with individuals that fall into this category. We support the same parts of the bill that the Attorney General's Office supports, the judiciary supports and we have opposition to the same parts.

So specifically on the issue of the three panel versus one individual doctor, changing it to one doctor is not going to speed up the process. It's not going to save money. It's really going to just increase the cost because the parties will then have to go out and probably hire private doctors to do their own evaluations.

And for our office that cost will be borne by the taxpayers court appointed attorneys for which the court appoints to defendants that our office cannot represent. That cost will be borne by the taxpayers.

If the prosecution seeks to have private doctors do evaluations, again, it falls onto the taxpayers, and not at the rate determined by the statute for the three panel, but based upon a private Doctor's own request for payment. So in the long run, it's going to cost more than what we currently have. You know, I think about it like this.

If you go to your regular doctor, your PCP, they won't diagnose you at the first time they see you with some sort of an illness. The doctor will tell you, I have to see you a couple of more times, run some tests, then I can make the diagnosis.

To have one doctor go and see someone for usually about an hour or so, have an opportunity to review that person's background and ask them to make a diagnosis and a finding of fitness is probably a disservice not just to the patient, and I'll say that patient, defendant, but also to the professional that has to make that finding.

And so there is a need to keep three members on the three panel, increasing the payment, opening up the panel possibility of panel members. These are all great things that will help and they address problems that the system currently has.

There's one other area that we do have some concerns about, though, and that is the repeated request for status conferences just so that the committee knows.

If a person is sent to the hospital because the court has found that person unfit and the need is for hospitalization for treatment and care, that person does not get lost in the system or end up being lost at the hospital.

When they are sent to the hospital, they're already given another court date to come back to court.

So the requirement of the bill to have status conference in 30 days, 14 days, and then subsequently weekly status conferences is just overly burdensome on everybody, including the judiciary, the public defender's office, the prosecutor's office, the Attorney General's Office, and even more so the staff of the hospital, because they'll be required to provide the court with status updates.

And I apologize, I was maybe a bit facetious in the testimony that was written here, but in reality, when you have weekly review hearings, most of the time what's going to be said is same thing as last week.

And I would ask you to trust me when I say that the staff at the hospital works very diligently to try to restore people to fitness.

And when they believe someone does not need to be hospitalized, they contact the court or they contact our office to let us know to Move the hearing up to have that person taken from the hospital and put into other placement.

So, you know, one of the things that we've all talked about, the stakeholders under this system, is we're really puzzled by why there was a need for this bill in the first place. And, you know, if there is a problem in the system, we believe through other procedural methods we can take care of those issues.

And the bill is really not necessary. But we're very open to further discussions in this area, and I'm happy to answer any questions. Thank you.

Thank you. Hawaii Disability Rights Center on Zoom. Please proceed.

Yes, thank you. Thank you. Good morning. I'm Lou Erticek. You know, listening to the testimony this morning confirms everything I thought over time, there's been a tendency to reduce three panels to one panel. And when you're talking about a petty misdemeanor, it may or may not be as crucial.

But when you come, when you're talking about felonies, the stakes are so high. And so over time, I've come to believe more and more in the law of unintended consequences. And so at first glance, I think the idea of going from three to one sounds like, okay, you're going to streamline the process, it's going to be quicker.

But if you listen to everybody this morning, the prosecutors and the public defenders rarely agree on everything, but they totally agree on this. The judiciary, the Attorney General. So all the folks who really deal with the system every day and know what's actually happening think this is a bad idea.

So I would urge the committee to take that advice. And that's really all I need to say this morning. Thank you.

Thank you. Hawaii Psychological Association.

Aloha. Good morning, chair, vice chair, committee members. My name is Alex Lichton. I'm the Legislative Chair for the Hawaii Psychological Association. As a forensic psychologist, I have conducted about 1500 fitness to exam examinations in Hawaii over the last 17 years. This bill attempts to address the delays in the process by reducing quality and reducing standards.

The sensible way to address the delays is to pass HB 264, which raises examiner fees to market levels so that more examiners can be hired. The other thing that can be done to speed up the process is to provide more resources for adult probation so that they can gather the records faster.

Changing the Chapter 704 laws will only make things worse. It will not address the delays adequately. The proposal to have one evaluation instead of three for felonies, it's opposed by all the stakeholders because it gives the judge less information for which to make a decision.

And I can tell you the inter rater agreement for first time fitness examinations is about 70%. Which means if you only have one examiner, you're going to reach the wrong conclusion about 30% of the time.

And then also in the mainland where you have maybe one examination, it's very common for the defense and the prosecutor to hire their own expert, which not only adds to the delay, but research has well established that there's at least an unconscious bias on the part of examiners to favor the party that hired them and is paying them by having more expedited cases for all nonviolent crimes.

That will increase the state hospital census. Under the current law, exams performed under those conditions, 95% of evaluates are found unfit to proceed and sent to the state hospital. Something is way off because nationally that rate should be 30% found unfit.

That's because this makes it very easy to malinger and be found unfit because there's not sufficient time to review. These exams would be done without any review of any collateral treatment or past records. So malingeris can get through easily. And it does not allow time for crystal methamphetamine induced psychosis to clear up. There's one provision.

The way this law is written, as mentioned earlier, the treating doctor at the state hospital could do the fitness evaluations for examinations. This is a violation. This is a dual role violation of the ethics code.

This Bill also allows advanced practice registered nurses to conduct the examinations even though they don't have the assessment training necessary to do this. If you look at forensic nursing programs, they train nurses to conduct counseling and therapy with forensically encumbered defendants. Assessment training is not part of that forensic nursing program.

So with all the problems in the bill, you might want to have maybe a working group to study this. But there's already a working group. The chapter 704 review committee meets every 10 years to make their recommendations.

A year from now, their work will be completed and all the stakeholders will have a chance to thoroughly review all this and come up with some consensus recommendation. So this bill undercuts that whole process. So I strongly urge you to defend. Thank you very much.

Thank you. Anyone else wishing to testify on SB 955 on Zoom or in person? Seeing none. Members, questions? I have a question for the Department of Health. As administrator of the state hospital, can you tell me what percentage of the population at the hospital are patients awaiting fitness exams?

So most of our patients are on the fitness. I mean, that's the 406s. That's the majority of our patients that are at the State Hospital, the 404s which are increasing the admission rate, which are.

If you could explain.

Sure. The judgment by the judiciary of 406 means they're unfit. So our goal at the Hawaii State Hospital is to restore to fitness so that they can get prosecuted and go on with their lives, deal with the crisis and help them with their mental health issues.

The 404s, which are the petty misdemeanants which this bill is trying to address, which is expediting those that have petty misdemeanants, and it's 50% of all are admissions that are coming from the hospital are in this category. You've heard that 30% really belong at the hospital. And that is true.

So that's even in our statistics that are coming through. So 2/3 of the admissions that are coming through as petty misdemeanants actually do need mental health or do not need mental health, inpatient psych.

They could be handled in a lower level of care in the community, in our jails and making sure that we take care of our patients versus if they truly are 406s, which means there's a judge that rendered this person unfit based upon all the evidence, then we will take them and restore them.

So the issue around this bill is to clarify where the patient is and what type. So for felonies, those kind of things, we still think there should be at least one, and that could be up to three. And there's no change here.

But for the petty misdemeanants, you really could have one examiner and move that patient back into the community rather than going up to the state hospital at the highest level of care.

The controversy seems to be the changing on felony cases to one examiner. Typically, how long does it take for a fitness exam to be completed?

So we are. They do it in two to three days, but it really should be a week if you look at inpatient care. So stabilization takes seven to 10 days. So by that time a psychiatrist, psychologist, APRN should be able to determine the course of treatment and really what is their status. So that is what we do.

If you go to Queens or you go to Castle to get emergency care, and that's really what it takes to render that. So the point being is within seven days we should know what this plan of care for this patient is. And for the petty misdemeanants, they really don't need to be at the state hospital.

Most likely they could be in a community, they could be in the jailhouse getting their treatment.

And as one of the testifiers said, you want enough time for if they are under the influence, that people kind of come off and they're no longer exhibiting mental health traits or symptoms because they're no longer high or on influence of drugs.

I heard the testimony from Hawaii Psychological Association that about the treating psychiatrist or treating clinician should perhaps not be a part of the examining panel, but is it appropriate for a kind of reproductive part to be done by the treating physician and be considered by the panel?

Absolutely, because that's already built into the process. Right. So the examiner should be one examiner or three examiners and the treating physician should have input to that.

That's the whole point, to make sure a treating physician is actually watching the patient, the examiner's relating doing an interview and then rendering a decision versus the treating physicians actually actively treating the patient with their team.

So is that not being done now? Do you need legislation to do that?

I think the legislation is to reduce the number of examiners so that you could leverage the attending as input to the court so you can expedite the process. And it's if you want to use three, you could do three. But the really issue is we already do the reports to the court for from the attending physician.

That's how we're getting them to Fitness Restoration, because they're giving status reports on our patients that they are fit to proceed.

Okay, but it's not explicit that the report be provided to the examiner. Correct. Okay, thank you. I don't have any other questions. If not, let's move on. Thank you very much. Thank you.

Sorry.

SB 1064 relating to medical cannabis. We have two medical cannabis. So this is number one. Department, let's see. Deputy Attorney General Alana Bryant.

Good morning, Chair, Vice Chair and Members of the Committee. Alana Bryant, Deputy Attorney General. I'll briefly summarize our office's comments. In the first new section of HRS chapter 329D that would be created by this Bill. The level of offense for subsection B is, it remains unclear and we recommend that it be clarified.

Our second comment is as to the new the second new section of HRS chapter 329D regarding cultivator licenses. Currently Section 329-130 only allows for dispensaries or qualified patients to produce medical cannabis. This new section would allow cultivators to produce cannabis that wouldn't be tracked, regulated or tested until it reached a dispensary.

Creating a new type of medical cannabis producer would also require the Department of Health to put additional resources toward investigation and regulation. We also note that the number of cultivator licenses should be specified and the appropriation amount should also be specified in the Bill. Thank you.

Okay. Thank you. Department of Health.

Morning. Chair, Vice Chair and Members Andrew Goff for the Office of Medical Cannabis Department of Health. This Bill would give the office enforcement authority against unlicensed cannabis dispensaries. We would note that if you are operating a cannabis dispensary without a license, it is currently a criminal violation already.

We have serious safety concerns about sending health inspectors into investigate criminal operations and we believe that should remain a law enforcement issue if we are going to move forward with this. I would note that on page three, lines nine through 15, there is an exception to the authority for hemp retailers and caregivers.

We would not consider hemp retailers or caregivers to be operating unlicensed dispensaries. So that exception is not really necessary and could create a loophole that could be abused by people operating.

Regarding the cultivator licenses, the Bill would create an unknown number of cultivator licenses that would be able to grow cannabis at a commercial level to supply the dispensaries. With the current demand, the dispensaries that we have are still not at full production capacity and we do allow wholesaling that should cover any shortages of supply.

So the issue is if there is an oversupply of cannabis and the dispensaries are not buying it, that creates a diversion risk. So I'm available for any questions that you may have. Thank you.

Thank you. Hawaii Cannabis Industry Association, Blake Oshiro.

Good morning. Chair, Vice Chair, Members of the Committee Blake Oshiro on behalf of the HICIA, the trade Association for the Licensed Medical Cannabis Dispensaries. So we are in support of the original part of this Bill which created more enforcement. We believe that the DOH needs as many tools as possible as we see a growing illicit market.

And we do think that they ultimately have discretion in terms of what they decide to enforce. And so giving them more authority or more tools is something that we support. We do not support the new addition of language in the SD2 that provides for cultivated licenses.

The problem with the industry right now is not that we don't have enough product. We have a lot of product. In fact, lots of the dispensaries are underutilized in terms of the production facilities. What we do have is a dropping number of qualified patients. In the last three years, it's gone down 15%.

And so if you have less people that are able to buy but more plants, you can figure out where the more plants is going to end up. And so therefore we don't support that part of it. Thanks very much.

Thank you.

Akamai Cannabis Consulting, Clifton Otto.

Good morning Chair, Vice Chair, Members of the Committee Dr. Clifton Otto offering comments. I just wanted to highlight one problem with this Bill, which is the state determining how much a physician or APRN can charge for a certifying evaluation and the registration and certification process.

I think the intent of this provision is that some patients are having difficulty meeting the fees that certifying providers are charging and this is due to the fact that because of the federal situation with cannabis, there is no CMS code for a medical cannabis evaluation. So this is not something that can be billed to insurance.

As a result, patients are paying out of pocket and fees can fluctuate widely and this can be a burden to patients.

But I think a better way to approach this is to ensure that certifying providers meet a certain level of competency so that patients are getting better quality care in the certification evaluation and follow up care so that there's actually a realized value of this Doctor patient relationship.

And so the amendment suggestion that I included in my written testimony is to have the Department adopt rules to establish standards for minimum competency for certifying providers. So thank you for considering my written testimony and I'll be available for any questions.

Thank you doctor. Noa Botanicals, Karlyn Laulusa.

Aloha Chairs, Vice Chair and Committee Members. Karlyn Laulusa, CEO for Noa Botanicals. I stand on my testimony and have some comments to offer. So like the trade Association, I am also in strong opposition of SB 1064 SD2.

I support the original intent of the Bill, which was to create a pathway to compliance rules and regulation related to the explosion of illegal dispensaries online and with retail storefronts. The illegal dispensaries continue to negatively negatively impact the participation rate.

So as Mr. Oshiro shared, our participation rate for last month was the lowest we've seen since October 2020. So the amendments made to date have discarded that intent and now focus introducing more cultivation licenses into an already declining medical market without a pathway to regulation, enforcement and enforcement of illegal operators.

So I recommend that the Bill be reverted to its original language in order to fulfill its original intent. Thank you and I'm available for questions.

Thank you. Cure Oahu, Mihoko Ito.

Good morning, Chair, Vice Chair, Members of the Committee Mihoko Ito on behalf of Cure Oahu, we concur with a lot of the industry comments that have been made, but we'd like to highlight two points. We do support the provisions that allow the Department of Health to issue cease and desist notices and have additional enforcement tools.

Clearly we have a problem right now that there is a lack of enforcement against these operators that are out there. You know, there are many, many examples of that in all communities across the state.

We do have an amendment that we think will alleviate the Department of Health's concerns, which is to also allow them to coordinate with law enforcement.

So it's not their people that are necessarily going out into the communities, but, you know, because that, I believe, has been one of the problems is the lack of coordination between the department and law enforcement to actually go after these folks.

Second, we have an amendment in our testimony that we've outlined that would actually streamline wholesale transport and wholesale purchasing by and between dispensaries. We'd ask the committee to consider that because right now, when products are bought at wholesale, they have to go to the production center no matter what, even if they're ready to be retail sold.

You know, you have to drive across the island wherever your production center is and bring them there, just because that's what it says in the current regulations. So I'd ask for the Committee's consideration on that and appreciate the opportunity to testify. Thank you.

Thank you. Oahu Cannabis Farm Alliance, Jason Hanley on Zoom. Please proceed.

Aloha, Chair and representatives. We're very excited to get a new chair into the HLT Committee. We're humbled. Our last chair, Representative Belatti, definitely did a lot of damage to the legacy market and the medical market that's not operating like dispensaries by not listening to us. I've had DOH on my farm several times. We've been working with legislators.

We introduced a Medical Cannabis Act of 2025 this year. Basically, the legacy market and the medical market of Hawaii is getting ignored right now and has been for over 25 years.

As you can see, a lot of the testimony coming in from dispensaries is law enforcement, law enforcement, law enforcement and continue to hurt people who truly need this medicine to get on with life, you know, and so we're hoping the health chair will really take a look at this.

The decline in registration cards is not because people are not going to dispensaries. It's because people don't want to get their card. Dispensaries are too expensive and they don't trust the government. And that's what's going on right now.

In my testimony right now, I put in the State of Maine, there's over 100,000 medical cards with a thriving medical system. And so this is the next big step we need to take is really getting on board with getting people licenses, getting people licensed that are not just the dispensaries.

And I put a lot of that in my testimony. But my cry to you guys today is law enforcement has been coming at us. Law enforcement has been doing a lot of damage. It's not true that law enforcement is not doing this.

They are hurting a lot of people who want to use medical cannabis that don't want to go to dispensaries. And there are no other avenues to respect the caregiver laws, to respect the people that are in the legacy market, that are trying to help people with their heart, not through criminal actions.

So we're glad to see a new health chair, sir, and we're just very excited to move on. The cultivation licenses are the way to move forward. There is not enough cannabis on this island. There's not enough cannabis in dispensaries. There's 1.5 million people, and there's eight dispensaries. People use cannabis. People want to get their licenses.

But right now, there's no trust. And we need further medical cannabis bills to build this trust and make a happy community in Hawaii. There's no reason for us to be fighting back and forth with Reefer Madness and cannabis. The medical Bill was passed in 2000, and it's solid in its landmark.

And we can move on from there with a new medical cannabis Bill that supports the local people of Hawaii with jobs and businesses and trust in building communities and taking care of our kaki. Thank you very much for your time, and I really appreciate it, and we're looking forward to the new health chairs.

Okay, thank you. Aloha Green, Apothecary Tai Cheng on Zoom, not present. Okay. That's all I have for testimony on SB 1064, unless I missed anyone on Zoom or in person. Members any questions? I do have a question for Department of Health.

You mentioned in your testimony that unlicensed dispensary operations are in fact just selling drugs illegally and it's a crime already. Is there any effort to work with state law enforcement to enforce such crimes?

Yeah. The Department of Health, we are currently engaging with law enforcement and with the Attorney General's Office and various prosecutors to come up with enforcement mechanisms.

Okay. All right, thank you. There being no more questions, let's move on to medical cannabis number two, SB 1429. And first up, the Deputy Attorney General, Alana Bryant.

Good morning, Chair, Vice Chair and Members of the Committee. Alana Bryant, Deputy Attorney General. To summarize our comments, current law generally allows for a one to one Ratio of caregivers to qualified patients. Increasing the number of patients to 5 per caregiver would allow a caregiver to grow up to 50 plants and create untested and untracked cannabis products.

The caregiver would also be able to purchase up to 20 ounces of cannabis products. We recommend keeping the number of patients to one per caregiver with the existing exceptions. We also recommend clarifying that the Department of Health's administrative penalties become final 20 days after service. Thank you.

Thank you.

Let's see.

Department of Health.

Morning, Chair and Members. Andrew Goff for the Office of Medical Cannabis Department of Health. This is an important Bill for us. It does allow caregivers to grow for patients again, but it also extends interim rulemaking authority for us to allow us to flexibility to create rules for the new program and extends exempt positions.

It's really important that we extend these positions. That is my entire dispensary staff. And without them, we can't do inspections. We would note that SD2 does increase the patients that caregivers can provide for from 1 to 5. As the Attorney General remarked, that does create some issues that gets more of a commercial level on the caregiver side.

So we would just ask that gets rolled back to one to one. Thanks. I'm available for any questions.

Okay, thank you. Hawaii Cannabis Industry Association. Blake o' Sher.

Chair, Members of the Committee, Blake O' sure. On behalf of the trade Association, we just wanted to provide some comments. So we are okay with the caregiver program. You know, one of our biggest concerns is a lack of enforcement. We were glad to see that the Bill has been amended to include some additional enforcement language.

Thank you.

And so we think that that is actually a prudent way to go. On the issue of the interim rulemaking, we would like to point out they've been under interim rules almost 10 years now since this law was first passed.

And at some point they need to make actually real rules so that it stops being interim and just being placeholders. Because there is our Chapter 91, which provides an entire process on how you're supposed to adopt administrative rules. And we do think that they should be following it, not going through an interim rule process. Again, thank you.

Thank you. Akamai cannabis consulting. Dr. Clifton Otto on Zoom Aloha.

Chair, Vice Chair, Members of the Committee, Dr. Clifton Otto, offering comments.

I just wanted to highlight that this is a very important Bill for patients because it removes the sunset on primary caregivers being able to cultivate for patients on islands with a dispensary this is supported by by Executive Order 2406 and the Governor's request that the Legislature address this issue this session.

And it also includes, as has been mentioned, expanding the caregiver ratio, which aligns with the current limit on five patients cultivating per property, which went into effect at the beginning of this year. So it would allow for patients to receive more assistance with cultivation, which is needed right now because a lot of patients have difficulty with cultivation.

It would also allow for a primary caregiver to go shopping and make purchases for more patients who are unable to transport to dispensaries. So I think there are two advantages there.

And hopefully the new enforcement provisions that have been added will make the Department of the Attorney General and the Department of Health feel comfortable that this is something that could be properly regulated. So thank you for considering my testimony. I'll be available for any comments or questions. Thank you.

Thank you.

Good morning. Mihoko Ito on behalf of Kira Oahu, we'd just like to echo the comments of the Association and really believe that the rulemaking, which was supposed to be interim, we think that the industry has matured enough that interim rulemaking is really not needed anymore. Thank you.

Okay, thank you. Oahu Green Apothecary wasn't here last time and still isn't. Noah Botanicals Carlin La Lusa.

Hello, Chair, Vice Chair and Committee Members. Carlin La Lusa CEO for NOAA Botanicals so I stand on my testimony and support the original intent of the Bill, including the staffing opportunities that the DOH consistently struggles with.

I do feel like the original language in the first draft would suffice in terms of protecting patient and caregiver rights in its simplest form. I also strongly feel that current enforcement opportunities need to be resolved, including the DoH's safety and well being when attempting to inspect a grow site. Right.

So when we're talking about caregiver rights and patient grow sites, these are private properties and it's dangerous to send them there.

And so to just continue to add to the list of things we're asking them to do, I think we need to stop and take pause and figure out how do we enforce to the current rules and regulations today.

And then I support both the industry and cure and I, I think majority of the licensees do in terms of the rulemaking and making a shift from interim to permanent. Thank you for the opportunity.

Thank you. Let's see, that's all I have listed to testify in SB 1429. Have I missed anyone, if not Members questions? Seeing none Department of Health, can I. You've heard testimony regarding interim rulemaking. Any thoughts that you can share with us on the status of.

Absolutely. So normally I would agree. Right. Chapter 91 does exist for a reason, however, in the cannabis realm, as I'm sure you folks have seen over the years. Every single year, a Bill comes. Every single year, the statute changes, the science changes. This is an emerging field that we need flexibility to be able to address.

So it is extremely difficult to do that. If you go through Chapter 91, we can start instituting more listening sessions and things like that to get public feedback, but just the mechanisms to go through.

It would take us almost a year to get rules in place, and then we'd be back here changing the laws and then another year to get the rules in place. So we would constantly be behind what the actual law is unless we have interim rulemaking authority.

Okay. The measure does propose extending the interim rules for two more years. That's correct. That's adequate.

I think we would prefer four, just to enable, you know, like I said, this law is not going to be finalized and stationary for another four years at least. So I think four would be our ask.

Okay. That would make 14 years. Okay, thank you. Thank you very much. Let's move on to the next Bill, SB 1281. Telehealth. And first we have Department of Health.

Good morning, Chair, Vice Chair, Members of the Committee, I'm Wanda Naonishi with the Department of Health. The Department stands by its written testimony offering comments, and we're available for questions. Mahalo.

Basically, you suggest extending the current law for another year, right?

Okay. Insurance Division, State of Hawaii, DCCA Good.

Yes.

Morning again, Chair, Vice Chair, Members of the Committee, Jerry Bump, acting Insurance Commissioner. You have our written testimony. I will just mention that we do support efforts to, you know, improve access to healthcare services.

There's a requirement in the Bill that insurers would be required to report the number of claims and different information related to the telehealth under this. So we've asked for, if that still moves forward, that we have explicit authority to collect that information.

There's also a concern we're not sure what the report resources would take to develop that report and include that in an annual report to the Legislature. So there could be some funding or staffing needs once that's determined, what that looks like.

Okay, thank you very much. Department of Human Services on zoom. Please proceed.

Aloha, Chair, Members of the Committee, Jean Moore Peterson, MEDCOS Administrator on behalf of the Department of Human Services and Director Yamane we stand on our written testimony offering comments. I will just note that we support our the amendment or the perspective the Department of Health was outlined. And so we are available for any questions. Thank you.

Okay, thank you.

Attorney General.

Good morning Chair, Vice Chair, Members of the Committee, Deputy Attorney General Andrew Kim. We've provided written comments just suggesting to. Put a savings clause protected against any contract impairment issues. Thank you.

Okay. Hawaii Primary Care Association Eric Abe.

Hi. Eric Abe for the Hawai' I Primary Care Association, I wanted to thank the chair for hearing this measure. From our organization's perspective, this might be one of the most consequential measures that the Legislature hears this year, especially as it relates to persons living on the neighbor islands Kupuna and also to the disabled.

If this Committee is inclined to extend Act 107, we would suggest that the Committee consider longer than one year just because of the time it would take the insurance division to come up with rules should they decide on how they want to implement the provision of non mental health audio only benefits and also the time it's going to take for administrative procedures to be exhausted.

I'd be happy to answer any questions.

Okay, thank you very much. AARP Hawaii.

Good morning Chair Takayama, Members of the Committee. I'm Audrey Suga Nakagawa, Advocacy Director for Aarp. AARP stands on its testimony in strong support of this measure and you know, we do recognize the value of telehealth that it does in terms of improving access to healthcare.

And from the perspective of the kupuna, this truly helps those who are homebound who have limited transportation options and just, you know, for those who live in the rural areas, especially on the neighbor islands and also to access medical specialists who sometimes are really hard to get ahold of, especially if they don't live on the same island.

And so we definitely recognize and really appreciate the continuation of having the services available as reimbursable. I just want to point out that we also appreciate having the audio only type of communications because we know not everyone is tech savvy and we also know it's not always reliable. There's not always reliable connectivity as well as affordability.

So thank you very much for allowing me to testify in support of this measure.

Thank you. Hawaii Association of Health Plans Rachel Wilkinson.

Good morning Chair, Vice Chair, Members of the Committee Rachel Wilkinson on behalf of the Hawaii Association of Health Plans, we have submitted testimony offering comments and while the Association strongly supports efforts to make behavioral health care more accessible, especially on the neighbor islands and in rural areas where brown bed broadband access and behavioral healthcare providers are kind of lacking.

We do have some concerns over the bill's current form regarding the expansion of audio only care. We also have concerns around reimbursement along with the proposed guardrail changes. And so the amendments proposed in this Bill pose significant risks and challenges that that really need to be addressed.

However, we would be supportive of the Department of Health's recommendation to extend the sunset date to December 31st of this year.

Okay, thank you. Thank you very much. Waianae Coast Comprehensive Health center on Zoom not present HMSA.

Hi, Good morning. Chair, Vice Chair, Members of the Committee Walden Au from HMSA I just wanted to offer a clarifying point that while we did offer a testimony in opposition to the bill, it's only in its current written form. HMSA stands committed to access to audio only behavior health care services through audio only Telehealth.

We're open to the suggestions and amendments provided by the Department of Health and we're available for any questions and thank you.

Okay, thank you. Hawaii Mental Health Coalition Melissa Pavlicek.

Aloha, I'm Melissa Pavlicek on behalf of the Hawaii Mental Health Coalition. We represent the Hawaii Psychological Association, the National Association of Social Workers, Hawaiian Islands. Marriage and Family Therapists and the Hawaii Counselors Association. We're in support of this measure.

Our number one priority is to ensure that the current law for reimbursing mental health services via Telehealth will lapse if this bill or a Bill doesn't pass this session. We would also support 100% reimbursement as well as continued audio only for establishing and maintaining the relationship.

But our number one priority is to ensure that the sunset does not cause these services to lapse. Thank you very much.

Thank you. Aloha Care Mike Nguyen on Zoom Good.

Morning, Chair, Vice Chair, Members of the Committee, Mike Nguyen, Public Policy Director for. Aloha Care we stand on our written. Testimony in support with comments.

We do serve about 70,000 Medicaid and duly eligible Medicaid and Medicare Members across the state, including Kupuna and residents in rural and also urban underserved areas that would benefit from accessing care via telehealth. So we do want to underscore our. Support for this measure on the principle of access to care, particularly for the.

Medicaid population, especially given our state's provider shortages. However, we do want to acknowledge the. Concerns raised by other stakeholders, particularly the. MedQuest division, and our testimony reflects that. So thank you for the opportunity to testify.

Thank you. Anyone else wishing to testify on SB 1281 missed. Anyone if not Members? Any questions? Seeing none, I don't have any. Let's move on. SB 1365 Interstate Medical Licensing Hawaii Medical Board DCC Good morning, Chair, Vice Chair.

Members of the Committee, Chelsea Fukunaga, on behalf of the Hawaii Medical Board, the Board will stand on its written testimony in support. The bill will enable the Board to fully participate in the Interstate Medical Compact as a designated State of principal licensure and allow physicians to apply for multi state licensure through Hawaii.

In addition, this would also assist the Board in Screening applicants to ensure that licenses are only issued to qualified, safe and competent physicians. Thank you.

Thank you. Ship. Jack. Dr. Jack Lewin.

Good morning, Chair, Vice Chair and Members of the Committee. Jack Lewin, Administrator, ship. We strongly support this bill. We think it's necessary and we stand available for questions. Thank you.

Thank you. Queens Health System. J.C. Mclennic, very strong support. Thank you. HMSA.

I didn't know I could do that from there. But we stand on our testimony in support of this bill. Thank you.

Thank you. I don't see any other test fires. Anyone else I missed if not questions. Question for DCCA, the Hawaii Medical Board. Quick question. You say in your testimony that to date. Well, the bill proposes that you be allowed to do criminal background checks on physicians using the interstate common.

You say to date, 202 physicians have been issued licenses to practice. Does that mean they haven't gone through background checks?

No. So they have gone through another state. This Bill would allow us to do the criminal background check, but they already have a compact license and so they can practice because we participate partially in the compact at this time.

Okay. Okay. And this legislation would enable. Enable us to issue the multi state license. Okay. Yeah. All right. Thank you very much. No other questions. Let's move on to SB 1509, Prescription Drugs Insurance Division, DCCA.

Hello, Chair, Vice Chair, Members of the Committee, Jerry Bump, Acting Insurance Commissioner, have our written testimony. We have a few comments to provide on this in section one of the bill it applies to.

We're a little unclear on what the intent is on who it applies to because it's, I guess, adding to Chapter 431 10A, which would not include potentially mutual benefit societies under Chapter 432 and perhaps health maintenance organizations or HMOs under 432. So if the intent is to include those entities, it would need to be restructured.

Our second comment is related to, I guess the requirements about that are being put into 431s, which is currently just a registration of PBMs. So we know which PBMs are operating in the state. If you're putting all these requirements in 431s, there's not, I guess, provisions that are authorized like enforcement.

There's various things that I think would be needed in order for us to sort of regulate this section. And then lastly, you know, with any new potential mandate, we do have that concern where an Auditor study needs to be performed and there's not been one. Not that's a new proposal to this specific measure. No.

Okay. Thank you very much. Thank You. Sorry, lost my place.Oh. State of Hawaii Planning and Development Agency, Shipta Aloha again.

Chair, Vice Chair, Members. Shipta supports this bill. We actually would accept the amendments that the insurance Commissioner raised to make it more broadly available. And they're the need for a potential need for an audit first to go for it. But we think this is a very.

Important measure to protect the pricing of pharmaceutical agents for those who are purchasing them themselves and particularly those of lower income. Thank you.

Thank you. National Community Pharmacists Association. Joel Kurtzman on Zoom.

Yes. Aloha Chair, Vice Chair, thank you for the opportunity to to share our strong support for Senate Bill 1509. Just quickly who we are. We represent independent pharmacy owners, including 44 in the State of Hawaii. We stand on our written testimony and remain available for questions specifically surrounding outcomes of PBM regulation from across the country.

I live and breathe PBM reform on behalf of the industry, so I would welcome any questions you may have. Thank you so much.

Thank you. Hawaii Association of Health Plans. Rachel Wilkinson.

Thank you. Chair, Vice Chair, Members of the Committee, Rachel Wilkinson, on behalf of the Hawaii Association of Health Plans, the Association stands on its written testimony and opposition. We appreciate the efforts of lawmakers to reduce out of pocket costs for prescription drugs.

However, we don't believe that passing drug rebates directly on to the consumers will achieve this goal. The complexities of factoring in the drug rebate is compounded by a lack of rebate transparency, extremely long lag times and unpredictable rebate amounts. It's also important to note that drug rebates are not the primary contributor to higher drug prices.

While we acknowledge that the drug rebate process isn't perfect, this legislation would lead to increased premiums impacting all health plan Members, including those who use non rebated prescription drugs. And we would also be open to an Auditor study as proposed by the DCCA Insurance Commissioner.

Thank you. Thank you very much. Kaiser Permanente on Zoom.

Thank you. Chair, Vice Chair and Committee Members on Kaiser Permanente stands. I'm sorry. John Kirimitsu for Kaiser Permanente. Kaiser Standzan's written testimony requested an amendment to exclude an HMO integrated health system from the definition of PBM.

Since we don't believe that the focus of this bill, which is centered around PBMs and achieving lower pass through drug rebates is targeted towards HMOs that own and operate their own pharmacies and be available for any questions. Thank you.

Okay. Thank you. Hawaii Pharmacist Association. Corey Sanders.

Aloha Chair, Vice Chair, Members of the Committee. I normally don't go really off script my submitted testimony, but I feel like this is pretty important and time sensitive. So I want to highlight some things that were in my testimony and then make some comments based on the testimony submitted by others. I want you to make no mistake.

It is the predatory practices of pharmacy benefit managers that are driving our independent and community pharmacists out of business across the State of Hawaii. To be transparent, there's about 15 to 20 ways we can tackle PBM reform, as Joel will gladly attest to if you have additional questions.

But right now, while we're working with other state stakeholders, what we can do to make the biggest impact is ensure that the fiscal lines of our independent pharmacies are protected, meaning that they're actually being reimbursed for the cost of labor and medication for all medications that they're dispensing.

In basic business terms, this lack of transparency is not in any other industry. There's no other service that provides the service and then is under reimbursed for the service that they provide. It's just not a sustainable business model. I want to comment on some of the other testimonies that were submitted.

The independent pharmacy market is anything but stable regardless of the national statistics across our state and specifically Foodland include closed all of their pharmacies in 2022. Pillbox Pharmacy in Kaimuki was in business for 46 years, closed a couple years ago and last year Walgreens, which is an unaffiliated chain pharmacy, announced nationwide closures that will affect our state.

I've got some statistics from some independent reporting agencies that have looked into PBM reform in other states. If you're happy to hear that information with questioning, I've got it prepared. But I want to point out the reimbursement rate floor that we're proposing. There is no data that this reimbursement rate floor directly increases premiums for healthcare companies.

And in fact in some other states when they're tightening the regulations around PBMs, the premiums actually increase at a rate that's lower than the national average. Should this measure pass out of Committee today, I can happily have discussions with the labor union to share that data. And then I'm also supportive of the amendments from Kaiser.

The DCCA supported a sunrise analysis. I will caution you that unless there is a legal battle or a state regulated formal investigation, the data is not going to be able to be got from the PBMs.

They are a dark hole for a very specific reason and I've seen in other states where because the verbiage isn't strong enough for them to release their data. I worry that the sunrise analysis needs to be strengthened with the verbiage and we're happy to work with the DCCA to do that.

The last thing I will say is that business fiscal lines for our independent pharmacies are so unpredictable that they can't rely on reimbursements of medication dispensing to maintain their business. So they rely on federal grants, state grants, or just other sources of income in General under the Current Federal Administration.

I'm sure you guys are feeling the strain of this too. Those federal and state grants are a little uncertain. And so in this time specifically, the best we can do is ensure that our independent pharmacies are reimbursed for the services at minimum that they're providing.

I will stand by for any questions and thank you for hearing this bill.

Thank you. Next we have Walgreens, Tiffany Gima.

Okay. PCMA Pharmaceutical Care Management Association.

Hello. Thank you. Chair and Members of the Committee. My name is Tanya Neal. I represent PCMA, the Pharmaceutical Care Management Trade Association. We are the national trade Association for pharmacy benefit managers. And pharmacy benefit managers are hired by health insured sponsors, employers, unions, government to provide tools to keep costs low and get the most affordable prices.

So we negotiate with manufacturers and we negotiate with pharmacies on behalf of those health plans. And some of the elements in the bill today are some of the tools that we utilize in order to keep those costs low and to provide services to the plan participants. We are opposed to this bill today.

It's basically doing some cost shifting. So breaking it down just a little bit. Manufacturers set the price of drugs and PBMs are one of the entities in the supply chain. So pharmacies have what's called a PSAO and health plans have what's called a pbm.

So who negotiate on their behalf to get the best prices for each of their respective sides. So specifically ERISA govern plans are mandated and governed by the Federal Government. Those plans are going to fall under this bill, creating some duplication and some questions about what they follow and whether or not they should be paying these higher costs.

Starting with point of sale rebates, which is the first part of the bill prior to the amendment. Point of sale rebates is again, it's a shifting, so it discourages the use of generics and it encourages or it allows some Members of a plan to get a benefit as opposed to the whole group.

So for example, if I went to Walgreens and I have a brand name drug which is all rebates apply to just the brand name, which are the more expensive drugs then I could be eligible under point of sale.

Currently, rebates go back to the whole plan and they're used by the plan sponsor to keep premiums low and keep cost sharing low. So point of sale won't be eligible for all drugs. Not everybody will get to benefit from it. Just a small group who are utilizing those brand drugs.

And brand drugs are about 10% of the amount of drugs that are in the, in the market today. So it's only going to benefit a few people, but it's going to cost everybody in the plans more money. Going on to the amendment where it increase adds in NAADAC dispensing fees.

Dispensing fees are an artificial price floor instead of allowing the market to set the price. And so when you add a mandated dispense fee with naadac. Naadac is a survey that is voluntary and not everybody, not all pharmacies have to participate with it. And because of that, you're not necessarily going to get reflective pricing from the market.

So it's going to have an inflated cost based on who's responding to that survey. The dispensing fee portion of it is, it's where you're setting up and saying, and I'll use it. For example, a drug costs $2 and you're going to add a dispensing fee of $10 onto that. So that drug just went to $12.

Where nothing about the drug change, it's just the handling and the handling didn't actually change. But the state would be applying a floor that increased the cost. Everybody's going to see that cost increase.

And so what we're asking is, what I'd like to ask is as the Committee maybe to back up and let us talk about some of these unintended consequences as a group and get everybody's input into it, everybody that's going to see these cost increases. We do have data.

There have been five states that have passed dispensing fee mandates in the last two and a half years. West Virginia has data, it has increased their cost. The other four states don't have data available because it just happened so recently or they're still in the regulatory process. But we do, we can literally put numbers to this.

And so I'd ask you to please summarize. Yeah.

In summary, what I'd ask is we would encourage the Committee to maybe back up, talk about it. Look at the fiscal impact and get some of that auditing information. And we're happy to be at the table and answer any questions. Thank you.

Okay, thank you. National labor alliance of Health Care Coalitions Fred Brown on Zoom.

Good afternoon, Mr. Chairman, Members of the Committee. My name is Fred Brown. I'm appearing today as President of the National Labor Alliance of Health Care Coalition, also known as the NLA. And I'm here to express concerns about Senate Bill 1509.

As it's written, the NLA is a large alliance of labor union and labor management healthcare purchasing funds that have formed multiple coalitions of health care purchasers. Each coalition is primarily comprised of Taft Hartley Union health funds. We are located throughout the United States with some in Canada and serve over 6 million combined covered lives.

We haven't talked about it today, but since the U.S. Supreme Court's 2020 decision in Rutledge vs.

PCMA, we have observed that at the behest of the independent pharmacy associations and the drug manufacturers, states all across the country have begun to systematically encroach on the ability of our health plan trustees to use pharmacy networks, mail orders and other plan design features that provide cost savings for our Member health plans in Hawaii.

We similarly find that Senate Bill 1509 as written undermines the ability of our trustees to design health plans in the best interest of our Member plan participants.

I provided a couple of examples in my written testimony, but I'll stop now and simply say, in short, we believe Senate Bill 1509 limits the ability of trustees to design health plans in the best interests of union Members and it undermines federal ERISA Preemption statute. Therefore, we urge a no vote on this measure as currently written.

Thank you.

Okay, thank you. Also on Zoom, I believe we have Chandra Kim, please proceed.

Good morning, My name is Chandra Kim and I'm a resident of Kailua, Hawaii. Since this bill ultimately affects Kamaina, thank you for this opportunity to testify. I support this measure which would pass PBM negotiated rebates on prescription medications through to patients.

PBMs have been a very confusing issue for a very long time and this is a great start to improve accessibility and affordability. My daughter lives with type 1 diabetes which if you aren't aware is a lifelong disease which with no cure. She requires a life saving drug daily in order to keep living.

Just as we require air to live, she requires air and injected insulin. The last thing I want is for her to worry about drug manufacturers, insurance companies and the so called middleman making decisions on her ability to receive her insulin. At a reasonable cost.

And I can tell you, the way things are now, any cost benefit is never in the patient's favor. We shouldn't worry about going to the pharmacy and finding out we cannot afford our medication. Especially when we know there are rebates available.

This bill would ensure that patients would pay the lowest negotiated price for that drug instead of the artificially inflated list price. My request is that you put patient needs on over corporate profits to help Kamaina. Thank you.

Thank you very much. See also on Zoom, we have Kimberlyn. Kimberly, Sweden believe. Please proceed.

Okay.

Kimberly, last chance. We can't connect. Okay. We'll have to move on.

Anyone I miss, can you hear me?

zero, yeah. There you go. Yeah.

Please proceed. Let me, let me. So, my name is Kimberly Mikami Svetton. I'm the President of Moloka E Drugs. I'm trying to work and testify at the same time. I appreciate the time to talk with you. I really wanted to use some examples that happened during the testimony prior to mine.

We are a pharmacy with rural rates, and so we are different than most pharmacies because we don't have any pharmacies that are near us. However, even with rural rates, with some of the pharmacy benefit management companies, we are not able to talk about situations based on our signed contracts.

And so a couple minutes ago, one of my pharmacists gave me an example of a prescription we just filled this morning. And I can tell you right now, we can't fill a prescription and have a loss of $57. That just happened a couple of minutes ago.

We are probably one of the few companies in the United States that we can't dictate our pricing and reimbursements. In the testimony that was submitted for SB 1509 Draft 1, I use as an example eggs.

So a Molokai grocery store selling one dozen eggs can instantly increase their price of goods or their price to the public from $9 a dozen to $11 a dozen. When the price of something goes up, we're not able to do that.

The example I use where we just lost a few minutes ago $57 on one prescription is just not sustainable. Another example I used in my written testimony is something that we do almost on a daily basis.

Every day, our Moloka E Drugs staff saves patients trips to the emergency room and Doctor's visits when patients are not able to set up appointments with their providers on the same day. Right now on island, we have what are called locums or temporary doctors and nurse practitioners on Molokai because people do not want to practice on island.

As of April 1, we are going from four dentists in 2024 to one full time dentist on Molokai, providing dental services for an island of over 7,000 people. So because we're accessible, we're open six days a week.

Sometimes patients can't get a Doctor's visit and they don't want to go to ER because they might have to pay a copay of $100. When a patient does not go to ER, they come to Molokai drugs and we're able to solve their problem.

At our little pharmacy, we have saved money not just for the patient, but for the insurance companies that provide medical, drug, dental, vision services. So an example I'm going to use is something that we do very often. A parent might come into a pharmacy for Uku or lice medicine for their child.

We are able to provide and work with providers and insurance insurers on getting that lice medicine immediately versus that patient having to take his or her child to the ER or the doctors for a prescription.

So pharmacies such as MolokaDrugs Save State and federal taxpayers such as myself, as well as insurance companies that are based not only in Hawaii, but mainly on the mainland money by preventing these expensive doctors and ER visits from minor health ailments on top of that.

Please wrap up. Thank you.

Okay, so basically, if this does not pass, you are going to start seeing more and more independent pharmacies closing, as well as major change like Walgreens and CVS Longs closing up some of their pharmacies. It is essential that this SB 1509 draft one goes to the next Committee. And we really appreciate this time. Thank you.

Thank you very much. Let's see, that's all the testifiers we have listed on 1509. Anyone else I missed or on Zoom? Yes. Please step forward.

Aloha, Chair. Vice Chair. Members of the Commission, Emmanuel Zibakalam here on behalf of the plumbers and fitters. We just wanted to chime in specifically on this measure because it does affect our union Members. We have a fully funded trust, meaning that we pay for the health care of our Members.

And with this measure moving forward, it will most likely increase our Members, or I should say decrease our ability to pay for their health care because due to the rebates that we receive back, we are able to then reduce the amount of that is paid for their health insurance moving forward.

And so it's for that reason that we respectfully request this Bill either be deferred or studied more. Thank you.

I'm sorry, the union you said you.

Represented plumbers and bidders.

Okay, thank you. Have I missed Anyone else on SB 1509, if not Members? Questions, Vice Chair?

Yeah. Thank you, Manny. If you don't mind coming back up, we heard a lot of testimony. In a nutshell, it's an opportunity to start sharing costs. We have an incredible need on the neighbor islands.

But what I heard loud and clear is our neighbor island pharmacies as we try and reset the floor, our neighbor island pharmacies are actually below the floor because they can't even cover the cost. And then you mentioned defer or study more.

Just really curious about what that study would look like and what kind of information are we trying to glean so that we can actually set the floor that's fair for everyone.

Thank you for the question. You know, it's probably outside of my wheelhouse to speak to the specific information that you would receive. What I would say is that we have multiple departments that can review that space and request it, whether it be the Auditor or another Department. If they do a study specifically for the union.

The reason that we bring it up is because we have 4800 plus Members across the state. And so when we speak about, you know, rural communities, our Members also live there. And so, you know, this is going to impact them, and especially the most vulnerable of them being the elderly, because we fully Fund our Members.

You know, when they put in the work, they've worked a long lifetime and they deserve what they get and this would impact their healthcare benefits greatly. Thank you, Chair.

Yeah, thank you.

Hi. Eric Garvey for the Hawaii Primary Care Association.

I hadn't planned on speaking on this Bill, but based on the discussions that occurred, you know, I think it's important to point out while I understand the testimony provided by Molokai Pharmacy and some of the independent pharmacies throughout the state, it should also be noted that many of these discount programs are specifically created to protect consumers and to protect the patients.

A good example of that is the 340B program. Some of the independent pharmacies do not participate in these rebate programs. And because of it, certain populations are being denied discount medications that they really should have access to.

A good example of this is what's happening on Lanai, where the one retail pharmacy on that island, they don't participate in the 340B program because of it the federally qualified health center on that island, which is required by law to actually provide this benefit to patients.

You're having to look at all of these different ways in order to get these medications to these patients. The same could be said on the island of Molokai. And arguably it's getting to a point where something has to be done.

I mean, ultimately, if this Legislature is committed to, to getting essential medications to patients, they're going to have to figure out some way of getting these medications to the patients.

Thank you. Thanks.

Any other questions?

There be no other questions. Let's move on to the next Bill, SB447 relating to Department of Health pilot program, Department of Health.

Aloha I'm Kenny Fink with the Department of Health. We support this measure that would allow us a pilot to pilot ways to facilitate filling civil service positions. Chair and Vice Chair. You might recall we met at the start of session and you asked me what are my top priorities.

I said my number one priority was was preventing a measles outbreak and my second priority was supporting Department staff. So this measure is an effort to support our staff. I will refer to our written testimony for more detail about that. I'll just simply add that we've been working with HGEA and we greatly appreciate their support on this.

Mahalo.

Thank you. Let's see. Department of Human Resource Development. Director Hashimoto.

Good morning. Chair, Vice Chair, Members of the Committee. I'm Branna Hashimoto, Director of the Department of Human Resources Development. We support efforts to increase the efficiency of the hiring process. However, we have specific concerns about this, the language in this Bill and specifically in Section 2.

We believe that as written, it conflicts with the civil service merit principle that's found in our state constitution and in Chapter 76 which requires equal pay for equal work, the return to work of injured employees and return reduction in force efforts to place employees who may be subject to layoffs.

We also find that the provisions in Section 2 violate the merit based pay programs and are based allow for non merit based compensation decisions. And we believe that it subjects the state to claims, possible claims of discrimination.

To address these concerns, we have offered alternate language for Section 2 which does require the Department of Health to establish policies and procedures that do conform with our civil service merit principles.

I'd also like to point out that we believe that this Bill is unnecessary as 765 already allows the Department of Human Resources Development to delegate to departments authority for doing certain personnel functions. In fact, Department of Health does have certain forms of delegation currently. And D Herd also allows currently four different forms of delegation.

So we believe that the Department of Health can utilize one of the programs that we already have in place that do comply with the civil service merit principles. And lastly, you know, D Herd is committed to continuing to work with the Department of Health to find a program that meets the their needs but doesn't violate the statute.

I'm available for any questions.

Thank you. Let's see, that's all the testifiers I have. Have I missed anyone else wishing to testify? Dr. Le.

Chair, Chair, Vice Chair, Members, I. I strongly support this effort on behalf of Director Fink's leadership here. Having been in his position, you know, three decades ago in the waihe years we, we had a similar problem. But in those days, we really filled most of our positions.

And today we're having a great deal of difficulty filling positions in critically important agencies like the DoH. So this kind of expedited action is going to be necessary if we want the workforce that we need to protect the health of our state. Thank you.

Thank you. Anyone else wishing to testify? Seeing none. Members questions? I do.

Zero, Representative Martin, I have A question for Dr. Fink. Have you taken a look at the De Herd recommended amendments?

Were you able to see their testimony? Not see their amendments?

Okay. I am wondering if with those amendments they would completely undo the benefits of the Bill since you hadn't had a chance to look at those. Maybe I'll ask Zihud to come up.

I would add, it is my understanding that the AG's office, if they saw legal concerns with the Bill, that they would testify. There was no shortage of testimony from the Attorney General's Office here today. So I think it's reasonable to conclude that they don't see a legal defect with the measure as currently drafted.

Thank you very much, dear. Please. Do you think that your proposed amendments would completely undo the purpose of the Bill?

Well, the purpose of the Bill, as I understand it, is to accelerate hiring. And we do have already delegated forms of delegation which do accelerate the hiring process. For example, right now D Herd is working on Operation Hire Hawaii, which is very similar to what Dr. Fink is attempting to accomplish.

However, the key difference is that we do screen all the applications and we do communicate with the applicants about their eligibility for civil service positions. And in doing so, we afford them due process, which Dr. Fink's process does not. And that's a huge concern for us.

And with respect to his comment about the Attorney General's Office and their review, we have asked for that, that contact and have not been provided it. And we have also shared with Dr. Fink the administrative rules specifically addressing the issue that, that we have a disagreement over.

And so as far as I'm concerned, it's in black and white. Can I ask a follow up question?

So this is a huge problem, not just for Department of Health, but Department of Human Services, Department of Agriculture, all. You know, it seems like our current rules are not working and any expedited programs that are in place right now are also not working.

It seems like we need to do a major revamp and I guess that's more of a comment than a question. Okay. But I'll leave it at that. Thank you.

Thank you, Representative.

Thank you. So how long does the average screening. Process take for applicants?

It can take. So we have our Wiki Wiki Hire program, which we've suggested Department of Health use. And if a Department signs up for Wiki Wiki, we commit to them that we will screen applications and refer qualified applicants to them every two weeks. So they're getting names every two weeks that apply.

And we've suggested that as a viable alternative to what they're suggesting. Typically, it really depends on the nature of the work. Some civil service classifications are very easy to screen. The minimum qualifications are pretty straightforward and we can do that fairly quickly. And others, there are a lot of substitutions.

So we have to really look at each application and determine which pathway an applicant might qualify. It's not as straightforward as just a degree or, or experience, but there's, you know, there's all sorts of substitutions in terms of alternate pathways or alternate degrees or coursework, in which case we would have to look at their transcripts.

And we do look at each and every applicant.

So a quick follow up, please, Chair, if I may. So when you're screening applicants, some of these jobs are highly specific. Does your agency actually have the expertise to fully analyze and determine whether the applicants are properly qualified or able to. Fill these roles, or is some of that screening better served by the Department.

Itself, who knows exactly what they need?

We are. So our Department, we have a team, our classification team, which works with the departments who have those jobs to develop the minimum qualification requirements. So we have, if we're unsure about whether somebody meets the criteria, we have points of contact in those departments that we can reach out to for assistance in guiding the process.

But we also De Heard has expertise in recruitment and classification, so we feel like we're capable of doing that work. Okay, thank you, Chair. Thank you.

If I could follow up with Dr. Fink. Dr. Fink, a lot of the testimony evolves around you breaking the rules and trying something different in your pilot program, which you've actually have been conducting for, I guess, more than a year between 2024 and January 20th.

So I was hoping you can maybe describe how your pilot program differs from the existing system.

It sounds, and maybe I'm wrong, but sounds like you have potential applicants walk in for an interview and rather than have them apply for a specific job, you fit the applicant's qualifications and experience and background to a job that would be appropriate to him or her. Is that correct?

So before we launch the pilot program, we currently have that we call the Hiring Innovation for Rapid Employment or Higher pilot program. We did check with the Attorney General's Office and we did consult with hga. The Attorney General's Office had no concerns at that time when we went live.

What we do differently is when we looked at our analysis and through like Six Sigma and trying to identify efficiency and steps that could be dropped or re engineered to improve efficiency. The delay in getting a list was often due to the verification of minimum qualifications.

And what happens is then the list that comes forward are folks who meet all the minimum qualifications and then those are the folks that you would offer an interview for and then you would select someone to proceed with, you know, conditional offer for hire. What we do is we don't screen out applicants.

We actually move them all forward so they all have the opportunity for an interview. And then only when the interview panel determines who is their first choice, we verify the minimum qualifications for that applicant. So what we've done is shorten the time from when the recruitment closes to the list of applicants gets to the program.

The program can interview more quickly. When people apply for a job, they need a job now. So we're able to get in contact with employees much more quickly. And then we don't waste that effort to verify minimum qualifications for people who are never offered the job.

So we have avoided over 100 minimum qualification verifications, which means our recruiters can do other work in other recruitments. What we do do is we make sure we notify folks who are not selected of their non selection again testimony today and previously that we are violating due process rights.

We again double checked with the Attorney General's Office and they reiterated last week that they do not have concerns with our pilot program. We defer to the General's office for legal matters and that's how they advised us. I'm sure they would be available to offer an opinion if asked by others.

So this process has proved to be efficient, more streamlined. We've had no complaints and no appeals and overall I would say this has been a clear success.

Thank you. Thank you.

Doctor, sorry, just a quick question. In that process where you've interviewed all these people in the pilot, have you ever found somebody who wasn't the first choice or wasn't qualified for a particular position and then turned around and suggested they apply for a different position that they are qualified for and filled in?

To my knowledge, there were three instances where the selectee was found not qualified and they needed to be notified. It's a different notification of being determined not qualified, which is different from non selection. And again we check the Attorney General's Office to ensure we're complying with the notification requirements in these three cases.

In one case, one was the only applicant, so we had to start all over. And we post in another case, that person was an 89 day hire and just didn't have enough experience to meet the duration of required experience. So it's going to be reposted when at least our 89 day hire would have had sufficient experience.

And in the third case, none of the applicants would have met, I think it was an epidemiological specialist. 4. None of them would have met the 4 level. So it was reposted as a 3.

So you still were able to find candidates and use them?

Yes.

Okay, thank you. There being no other questions. Let's move on. Members, we have three more bills. The next bill we have posted on the agenda is SB 1494 relating to hearing aids for those who have may have missed it. We did move that bill up to the top of the agenda because we needed a translator available.

And for your info, we deferred the bill pending a possible audit that could be provided by Concurrent Resolution. So let's move on to SB 838 relating to health insurance again. And this would require the coverage of continuous glucose monitors. And first up, we have the Insurance Division DCCA still.

Good morning, Chair, Vice Chair, Members of. The Committee, Jerry Bump, acting Insurance Commissioner. You have our written testimony. The two main concerns, or just comments, not really concerns, is, you know, anytime. You mandate a new benefit, there's in. Statute a requirement to have a study. Done by the State Auditor. The second concern is whether or not.

This would trigger a defrayment under the. Federal regulations if the state mandates this benefit and it's not part of the essential health benefits. That's all. And I'm available for any questions. Thank you.

Thank you. Dr. Jack Lewin, Shipta. zero, we lost Dr. Lewin. Okay. Kaiser Permanente.

Hi, good morning again. Thank you, Chair, Vice Chair and Committee Members for the opportunity to testify. John Kirimitsu for Kaiser Permanente. Kaiser stands on his testimony offering comments. Kaiser supports the glucose monitoring to maintain glucose targets, but we think that the bill may be unnecessary because there's already existing statutory diabetes law requiring coverage for diabetes equipment.

So this bill may be unnecessary. We also support an impact assessment audit since this is considerably being proposed as a new mandate. Thank you.

Okay, thank you. Hawaii Association of Health Plans, Rachel Wilkinson.

Thank you, Chair, Vice Chair, Members of. The Committee, Rachel Wilkinson, on behalf of the Hawaii Association of Health Plans, we stand in our testimony offering comments and I want to highlight that this bill would create a new mandated benefit and any new benefits would increase costs that could affect employers and residents in Hawaii.

And we would also respectfully request that. The State Auditor conduct an impact assessment report pursuant to HRS. 2351 and 52.

Okay, thank you, Dr. Lewin, while you're here.

Thank you. Chair, Vice Chair, Members. We're on 838, correct? Yes. Yes. Okay. This, this really is an important bill for me. Just an anecdote story. Our secretary at Shipta had an unstable diabetes situation. She was on two kinds of insulin and her Doctor requested a continuous glucose monitor, which she needed, and it was denied.

And tragically, she passed away. And this is something that there's no blame here. I'm not trying to put any blame out there, but I think this kind of instrument for certain kinds of diabetic patients is incredibly important.

It's not for everybody because it's about a $3,000 a year cost or $300 a month, but for those who have swings of blood sugar, very high and very low, both conditions, very dangerous. This is a powerful way for the patient to educate herself or himself about how to manage their lifestyle and their medication.

So I think we're a little behind as a state in terms of providing this kind of service for patients. So I just want to make the point of how important it is for the appropriate patients. And thank you very much.

Thank you. On zoom, I think we have Esther Smith, Mohala Health. Please proceed.

Good day, Chair, Vice Chair and the rest of the Committee. In the time of this meeting, I have seen six patients. It's no first, forgive me for being a little bit wide ranging at the end. I am here to testify in strong support of SB 838 and the current version.

This bill is here to provide continuous glucose monitors, which we already know is a life saving tool for diabetes measurement management. But this fight is bigger than CGMs. Every time the insurance companies place a barrier between patients and their recommended care, whether it's denying CGMS or forcing doctors to long prior authorization delays, it's cost containment.

But when they block care and the Legislature tries to remove blocks to those care, it's an unfunded mandate. They want to dictate medical decisions without facing any responsibility for the harm they cause. If a patient ends up in the emergency room because they couldn't afford a CGM or because their Doctor had to fight a prior authorization.

And the problems that have caused those delays fall on the hospitals, the physicians, families and taxpayers. You don't get to hear from any primary care providers directly because we're too busy. I am more than 1% of the primary care on Big Island right now. I couldn't take the day off to be there.

Just two examples of why CGMs are important and how it works. Now, the people for whom CGMs are covered, like my patient who has a severe visual impairment, has had a stroke, is on insulin and has had some really variable blood sugars, those are covered.

But I will tell you that when I go to the major insurer's website to find the form to get the prior authorization, it doesn't exist. So what they have me do, I send the prescription, the prescription is refused, I try to find the form, form does not exist. I send the wrong form on purpose.

So they send me the right form and then I send it back. And I am doing all of that work because self same major insurance company has offshored their billing such that people, people like me are being wildly underpaid right now.

Doctor, I'm going to ask you to please wrap up. Thank you.

Briefly, just the last bit. The people for whom CGMs are not being covered are people like people that aren't on insulin who are at the beginning of their diabetes journey. And sometimes when you intervene with something like a CGM at the beginning of somebody's diabetes journey, you may actually be able to reverse the disease.

And when you do that, you are saving thousands upon thousands upon thousands of dollars over the lifetime of that patient. You can learn a lot from a CGM, which is super important because we don't have diabetic educators. The insurance companies don't have to pay for those diabetic educators. They need to pay for those CGMs.

Thank you. We hear you. Thank you, Dr. HMSA Don Carriso, not Dom.

Only one more time. Morning Chair, Vice Chair, Members of Committee, we just stand on our written comments.

We just want to clarify though that Section 6, which looks to exempt this from an Auditor study was at the Recommendation of the AGs in the one of the earlier committees because at the time there was no Concurrent Resolution or a resolution for a study for this.

But if you look now, HCR 171, HR 167, SER 120 and SR 101 are both in both chambers looking to provide a study for this. So thank you.

Thank you. And on zoom, Lisa Rance, please proceed.

Aloha. Thank you Chair Takayama and Vice Chair Keokapu, and Lee Loy. It's my pleasure to be here via zoom to speak on behalf of the community.

I am the Executive Director of the Hilo Benioff Medical center foundation and have the privilege of serving as the State Association Council chair for the National Rural Health Association, which means I dovetail and provide technical support to all the rural health associations across the nation. In my testimony, I did provide a map.

CGMs in most of the states are a prescription benefit. In our state, all of the insurance companies say that they cover it. The reason why we need this bill and that we're trying to have it as a mandate is because it's inconsistently covered. We.

Took on a project between August and January, and this came to us by a dear friend and a board Member, rep. Nakashima, who, you know, succumbed to his diabetes last year. And so this is very near and dear to my heart. We went to all of the regions and held diabetes care community gatherings.

We wanted to hear from those impacted by diabetes, from their caregivers, the healthcare providers, social workers, and community advocates that are working in this space. And what we found is the longer folks have diabetes, the less support they feel that they get from their healthcare providers and they have lost hope. We don't need more dialysis centers.

We need to give people a tool that they can use that is already covered by insurance. So it does not need a study. Because if you look at all the plans, they say that they cover it. In the testimony, they say that they cover it, but we need something from the Legislature.

So Dru Kanuha put this bill forward after attending the diabetes care gathering in Kealakekua because he was so moved by the testimony and the comments of our community Members. We have an example that I can share with you of a married couple that live in Pahala, very rural area.

They are on the same managed care plan and the husband has advanced diabetes with amputations. His providers have not been able to get him a glucose monitor. His wife moved from pre diabetes to diabetes in this past year and she has a glucose monitor.

Thank you very much.

So it is very inconsistent.

Thank you.

So I urge you to pass this Bill.

Thank you. We appreciate your testimony. Thank you. Anyone else wishing to testify on SB 838? Yes. Please step forward.

Good morning, chair. Good morning, Vice Chair. My name is David say. I'm the Executive Director of Mahala Health. Not to take so much time, but I just want to talk about this in four points. And the first point is it is a public health crisis. We have about 108,000 plus residents in Hawaii living with this issue.

We know the benefits of cgm, so there's no need to talk about that. We know the proven outcomes of this, so we don't need to talk about that. The major issue here, from my point of view, is the insurance barriers. So while CGMs are technically covered by most insurance plans, the approval process is inconsistent and burdensome.

So that's where it's at. You know, we have our patients who get tired of this and they just fall off the bandwagon and it gets bad. So I would like for us to look into that part, and that really stitches it up. Thank you.

Thank you. Anyone else wishing to testify, if not Members, questions. And by the way, Members, I, I do think as worthy as this is, it does require a sunrise audit. So just for your information.

Okay , there being no other questions, let's move on to the last two bills and I'm going to ask testifiers to please try and hold yourself to two minutes if we can. We do need to get through these last two bills and then vote on them. SB 1449 relating to prior authorization. First up, Dr. Jack Lewin.

Good morning again, chair, Vice Chair and honorable Members. This bill is an important bill for SHIPTA and for the state.

It does provide a means to it provides a means to have an understanding, some transparency about prior authorization, which, as you know, is a very controversial topic nationally as well as here, and one that we think at SHIPTA could be resolved by a collaboration between insurers, providers and those who purchase insurance like EUTF.

That's what this bill would provide, the transparency part to it.

We'd like to I want to thank this Committee for passing on House Bill 250 on your side, which had an additional feature which was a collaboration working group to get together and decide on the standards and then allow and facilitate the automation of the process in the future, which will be a benefit for the insurers, doctors and the purchasers.

So I've added that language in the back and I just want to mention that in the language added, the Attorney General asked me to remove a couple of the new definitions that didn't weren't consistent with SHIPTA. So the language that's here would be the perfect addition if you chose to add it. Thank you very much and mahalo.

Thank you. Hawaii Association of Health Plans. Rachel Wilkinson.

Thank you. Chair, Vice Chair, Members of the Committee. Rachel Wilkinson on behalf of the Hawaii Association of Health Plans, we're going to stand in our written testimony offering comments. I also want to say that the.

Association appreciates the efforts of lawmakers to try and address prior authorization improvements, and I think we can all agree that this is a very nuanced and complicated issue. We also want to ensure that the reporting noted in this bill aligns with current CMS regulations that are set to. Be implemented in 2026.

And note that we would be willing. To participate in further conversations with lawmakers and other stakeholders. Thank you.

Thank you. Thank you very much. Hawaii Medical Association Elizabeth Ignacio on Zoom.

Aloha. Good morning. Chair Takayama and Committee Dr. Elizabeth, Hawaii Medical Association, a Maui Physic we do stand on our supportive testimony for SB 1449. We support the reporting provisions in this bill. HMA does feel that the addition of Healthcare Appropriateness and Necessity Workgroup would be an important addition for consensus and automation of future PA improvements in Hawaii.

We are available for questions Chair.

Thank you. HMSA. Dawn Kurisu.

Good morning. Chair Vice Chair, Members of the Committee, first off, we just want to. I'm Dawn Kurisu, on behalf of HMSA, first off, we just want to thank the Committee for really taking the time to listen to stakeholders and understand that we are all committed to working together to lessen administrative burden and improve the prior authorization process.

HMSA will stand on its written comments, but just want to highlight on this measure that we believe through many discussions and iterations of prior authorization bills this session, we're really hopeful that the Committee is open to keeping the language of SB 1449 SD1 intact.

And note that we are certainly open to the addition of the working group outlined in HB250HD2. We believe that a working group is critical to continue to assess the ongoing evolution of prior authorization given new CMS requirements being implemented already in 2026.

We also deeply respect our providers and the feedback that they continue to share and are amicable to the proposed amendments suggested by HMA and their testimony.

Again, we just want to reiterate that we are committed to working together with the various stakeholders to ensure that prior authorization is efficient, definitely less burdensome, and that it continues to ensure the best care for all of those that we love. So mahalo. Available for any questions.

Thank you very much. Kelly Withey. Dr. Withey.

Good morning. Kelly Withey, I will stand on my. Testimony in strong, strong, strong, strong, strong. Strong support because it's the number one. Thing you can do to to help. Healthcare providers and patients in this legislative session. Well, there's also telehealth but very important. Thanks.

Thank you. Your support. Austin Salcedo.

Aloha Chair. Co chair. I strongly oppose Senate Bill 1449, but it may be not in context. But this is the only opportunity that I've seen the ship that has guidelines, standards and policies to be incorporated by the insurances with this covering operations that's happening. I'll give an example. In Makah, an area Shipta.

We found out that Shipta had certified this operation for drug rehab, alcohol rehabilitation. And what I'm trying to bring up is this operation was put on a commercial property near children's schools in close proximity where they commute to and from schools. Okay.

So these type of things I'm asking for to be amended to insert languages in and such because these are basically operations that certified by Shipta itself. They issue out cons certificate of need and only them they're not transparent to the community that we live in. Never came before a board.

So I leave this out of context as far as approval. But they use insurances, standards and everything. But we have no idea in the west side that's being inputted into our community. And there needs to be an insertion where they collaborate equally with the city.

DPP for conditional use permit Major other than that, our community doesn't know about this entity moving in except we see businesses open, people walking in and out knowingly. This is for drug rehab. This is special treatment under Shipta. And other things is being under operated by the state that the city doesn't know about.

There's no lack of transparency, including the governor's emergency proclamation for rise that came in from Kailua operations in an area where there's close to less than 300ft from a nursing home and 800ft from a preschool on the same street. Safety is a public safety is a concern. So I'm. If it applies to this, please incorporate it.

That's my amendment to this thing. So I think it's an important for transparency. If they talk about transparency of standards and guidelines and operations. That's all I have. Thank you.

Thank you. I appreciate your coming here to voice your frustration. Mr. Salcedo. Your testimony doesn't directly affect I mean the bill that we're discussing, but there are other legislation that may still be alive that does affect Shipta.

This is the only thing I had caught wind of as far as Shipta is concerned.

No, I understand.

Yeah. Thank you very much. Does apply. Does apply.

But thank you for coming Anyone else wishing to testify on SB 1449? If not, members, questions? If not. Let's move on to the final bill on the agenda, SB 1040 relating to medical debt and Dr. Jack Lewin.

Good morning again, chair, vice chair, and members. Jack Lewin, SHPDA. We strongly support this bill. Medical debt is not part of most developed nation societies because the healthcare system covers the needs of the patients more appropriately than what's happening here.

So I'd like to see from SHPDA's point of view the elimination of medical debt over the next decade as we work together. This bill, however, just allows our sister agency and the governor's office to actually quantify what the needs are and try to resolve the problem for people who experience medical debt now.