March 31, 2026 · Health & Human Services · 92,543 words · 16 speakers · 306 segments
Health and Human Services Committee will come to order. Mr. Chidung, please call the roll.
Representers of the Brown. Radfield. Excuse. English. Excused. Frey. Presente. Hamrick. Here. Johnson. Here. McCormick. Here. Wrighton. Here. Stewart. Here. Winter. Woog. Excused. Leader. Present. Madam Chair. Present.
Okay, welcome everyone. We have quite the full hearing today. We are going to be hearing House Bills 1336, 1328, 1314, and 1267. We will have two minutes each for witness testimony and 10-minute panels. And with that, I think we can go ahead and get started. Welcome, sponsors. Representative Lindsay.
Thank you, Madam Chair. Thank you, committee. I am excited to be here today with my co-prime AML Winter to present House Bill 1336. in communities like mine I represent northwest Aurora families face real barriers to care including costs, transportation and also long wait times for basic services a lot of people in my community don't always have insurance or are able to afford the cost of additional care it's a rampant issue where I live and this is a statewide issue Very few parts of Colorado have enough providers to meet demand, which leads to delays and worse outcomes. And what I find very interesting, and which has come up in my work here, is the similarities between my district in northwest Aurora and the rural areas, in that they are both underserved communities in different ways and for a variety of reasons. But that's, I think, why you'll find every time I run a pharmacy bill, it is with a member from a rural area because we are looking to address the same needs. This bill takes a patient-centered approach and at its core is a carefully structured test and treat model. That model is limited, targeted, and evidence-based. It applies only to minor self-limiting conditions or those guided by simple, highly reliable CLIA wave tests. Treatment is provided only when a test confirms the condition, and patients are referred when symptoms fall outside of those parameters. In many ways, this strengthens care, because it ensures appropriate treatment based on confirmed results, while reducing unnecessary delays. And importantly, Colorado is currently more restrictive than most other states, even as others safely allow broader access to these same services. This bill and the amendment which we're bringing strike a balanced path forward by expanding access while maintaining strong safeguards. Our amendment establishes a five and up threshold for test and treat services and requires communication with a primary care provider or referral to support continuity of care in the medical home. This bill also addresses a key equity issue by ensuring patients can access and afford care in pharmacy settings particularly for Medicaid patients who are often pushed into higher cost care today It strengthens the system through team care models like technician product verification while clarifying that controlled substances are not included. And we work directly with health insurance carriers to ensure the bill clearly reflects that this is not an any willing provider policy. Ultimately, this is about expanding safe, timely access to care while maintaining the guardrails patients and providers expect. And as I've said many times before, I'm a mother of four. They're all grown up now, thank goodness. But we had four kids in five years. And so as we would take them, or if something was happening in our household and kids were getting sick, access to very quick care or diagnosis was always really important. And it was oftentimes that we couldn't be seen at our regular pediatrician in a short enough time. Sometimes we didn't have insurance to rely on at all. And then sometimes it got to the point where we had kids of a certain age here and then kids under like the threshold that currently exists in statute. So I look at this bill from not only my community perspective of how we can increase access to services for people who don't have the traditional, like we would all love for people to have be well-insured and have access to their doctor in a timely manner. That is not the real life experience of so many people in our communities. And that is why we bring this bill. We look forward to the discussion and we urge an aye vote. Thank you.
Hey, Mel Winter. Good afternoon, Chair Gilchrist in committee. Thank you for hearing this bill this afternoon. Colorado is facing a serious primary care shortage and in rural communities like mine, that means delays, long drives, or going without care whatsoever. We're not going to build our way out of this oversight. We need to better utilize the providers that are already serving these communities. Pharmacists are often the most accessible healthcare professionals. Nearly 90% of Americans live within five miles of a pharmacy, and in many towns, they are the front door to care. At the heart of this bill is a simple concept. Test and treat. A patient can walk into a pharmacy, receive a rapid test for flu, strep, or COVID, and if positive, receive timely treatment on the spot. That care that is faster, closer to home and far less expensive than sending someone to urgent care or the emergency room. Right now, Colorado law allows pharmacists to administer these tests at any age, but if a child under 12 tests positive, the pharmacist cannot treat them, forcing families into costly and care-delaying situations. And it's worth noting, Colorado is one of the most restrictive states in the country, where more than 20 states allow pharmacists test and treat with no age limit. This bill takes a measured step forward, especially with the amendment we are bringing. Establishing five years and older for test and treat services, requiring notification to a primary care provider or referral if one is not identified to reinforce the medical home. It also ensures pharmacists can be reimbursed for services already covered instead of pushing patients into higher cost settings. And it includes technician product verification, allowing pharmacists to spend more time on patient care while maintaining full clinical oversight, while making clear controlled substances are not part of the model. Finally, we work directly with health insurance carriers to clarify that this is not in any willing provider framework. This is common sense negotiated solution that improves access lowers costs and works for House District 47 With that I urge an aye vote Thank you Thank you sponsors Questions from the committee
Representative McCormick.
Thank you, Madam Chair. You had mentioned that other states have done this. Have they also had this age range in those other states? I think you said 20 other states. I'm just curious about the age range in the other states as well.
Give me one second. Give me one second to find it. I know we have it in here. Sorry, Madam Chair, give me a minute.
No problem.
So there is no age limit in those 20 states.
Representative Johnson, also just wanted to note that Representative Wug and Representative Bradfield have joined us.
Thank you, Madam Chair, and thank you, Sponsor, so much for bringing this. I mean, I preach rural Colorado all the time, need resources. I see the urban collaboration. My question is, because I know pharmacies not only help bridge the barrier of lack of access, but they also bridge Medicare. Not Medicare, sorry, health care aspects. When I was seeing five to six different doctors, my pharmacist was the consistent. They were able to help direct me. I didn't have to go to Denver as many times to get some of the needed testing done. And so I'm just curious if you've heard support from other groups as well, not just the lack of care, but looking at, you know, chronic issues and people on multiple, you know, health providers and them being the connecting point. And really, this helps them
continue to be that connecting point. Representative Lindsay.
Thank you, Madam Chair. And thank you for that question, Rep. Johnson. I think that is actually an experience that many people have across the state when in that relationship with their pharmacist, and especially considering that a lot of pharmacies are in your neighborhood or in your grocery store. So every time you are going about your daily life, you have that touch point with this access to health care. And so I think, yes, that is actually a pretty common occurrence that people see that pharmacists or have more access to it than they do their regular, even
doctor's office. Emma Winter. Thank you, Madam Chair. So I don't know how many of you all have been into a little rural pharmacy, but I'm going to paint a picture. First and foremost, you're 100% correct. I have a friend recently who their pharmacist caught that where there had been a doctor and put them on conflicting drugs and was able to avert something from happening right there on the spot. But the small rural pharmacy is not just a place that you go into. There's all these pharmacies tech. I mean, it's the place where you go in. You probably know your pharmacist personally because he's part of your community. He has a vested interest in the community. You can buy a birthday card there, fishing, tackle, a gift for somebody. It's kind of like a center for a community. And I think it's important to realize that especially in rural Colorado, we have those relationships. I think it's hard in the everyday hustle and bustle of urban life to understand, you know, there is Mayberry still out there. And they are the front door. We go to them for everything. We live in communities where some people may not have a big box store to go to for medicine or anything that is around that area. And these pharmacists actually really look into their communities. You're going to hear from a pharmacist in my district who actually bought pharmacies in other counties that were going to close because he wanted to be able to provide that care throughout the district. So they're really invested in their communities. And I just want you, as you think about this bill, not to think about the big box pharmacy that you walk in, not to think about the big pharmacy you walk in. Think about that little pharmacy that is really the stopgap for those that need access to care And they also take a lot of overflow now from doctor offices So I think that important to note too So just remember that when we talk about this especially for House District 47, it's a little bit different world than what you see in the big box stores and what you see in the larger pharmacies that you go in every day.
Additional questions from the committee? Okay, seeing none, we'll move on to witness testimony. I should have asked what the... We'll start with the first panel, Dr. Zedvorni, Dr. Gina Moore, Dr. Kai Davis, and Dr. Kim Ward. Thank you. Dr. Sarah Billups. And Dr. Andrea Crow. Okay, while the remainder of the folks are being pulled up online, we'll start from my left to my right. If you could introduce yourself, your organization that you represent, and you have two minutes. Go ahead. And there's a tiny little button. She's on. Thank you. Good afternoon, Madam Chair and members of the committee. My name is Sarah Wise,
and I'm a pharmacist at Clear Spring Pharmacy. It's an independent pharmacy here in Denver in the Cherry Creek location. At our pharmacy, we provide out-of-pocket prescribing services for self-limiting conditions, such as influenza and cold source, where timely treatment does matter. We serve both longtime community members and a lot of travelers who rely on us for walk-in care. Recently, I had to turn away a mother that was visiting Denver with her two children. She was seeking preventative influenza medication, and their father had just tested positive for the flu. And both children have asthma, placing them at higher risk for complications. One child was eight years old, and because of current age restrictions, I was unable to provide care. It was a Saturday, their pediatrician was unavailable, and the antiviral medication is most effective when started as soon as possible. She left understandably upset, facing delays and higher costs to get care for her family. This is exactly the type of gap that House Bill 1336 is designed to address. Pharmacists are highly trained medication experts. we already follow strict guideline-based protocols and refer patients to higher levels of care when needed. This bill does not replace physicians. It complements them by helping us serve patients with treatable, self-limiting conditions. Modifying the age restriction would allow us to treat the whole family, not just part of it, ensuring timely, evidence-based care for all patients. Additionally, fair reimbursement for pharmacists services is critical to sustain and expand access, particularly in community-based settings like mine, where we often serve as a first point of care. As a pharmacist in Denver, I strongly believe this bill will improve access to timely care, reduce unnecessary health care costs for families living in and traveling through our state, reduce strain on emergency departments and urgent care centers, and ultimately improve
health outcomes in my urban community. Thank you for your time. Thank you so much. Please proceed.
Thank you, Madam Chair. My name is Emily Zadvorny. Some of you know me as the CEO of the Colorado Pharmacist Society. We've been working on this bill for two years and stakeholding it for almost two years. So we represent pharmacists in all practice settings, which this bill applies to. So it could be in a clinic, it could be in a community pharmacy, it could be in long-term care. I'm also a pharmacist. I practiced in a medical home collaboratively for 20 years, and I'm very, very proud and protective of the care pharmacists provide. We take oaths when we enter practice to safely and effectively provide care for patients. Thank you, Reps Lindsay and Winter, for sponsoring this bill. I don't know about you guys, but if we are going to continue to talk about challenges to our state with provider shortages, access problems, the public health issues, Medicaid cuts, rural health transformation, healthcare deserts. We can't keep talking about these things without offering solutions. We have a group of providers that is offering to help. They are highly trained, they are ready, and it is effective other places. So most of what you see in this bill already exists in other states, already exists in other countries, and we are simply behind in Colorado. increasing the age range that we can treat is not a scope expansion it's an age expansion and it was brought to us because our communities and families are asking for that if provider offices were open extended hours and on weekends and everyone had a medical home and everyone has insurance this wouldn't be something we were offering this is not a self interest bill. This is a group of providers that would add the service to help patients in Colorado. Not allowing it just gets rid of a whole group of providers that could be helping with some of these problems. The other components, technician product verification has been studied. It's safe, it's effective, so we would like that for efficiencies in our own workplace settings. And then reimbursement is just something we have to do. It's saying we value as a provider for providing those services. We will pay you just like we pay anyone else. So I implore you to support this bill. It doesn't hurt us. If you don't support this bill, it hurts families and communities.
Thank you. Thank you for your testimony. Please proceed.
Thank you. Madam Chair and members of the committee, thank you for the opportunity to testify today. My name is Sarah Billups. I am a pharmacist and pharmacy professor at the University of Colorado, where I serve as Director of Population Health Pharmacy, supporting a team of primary care pharmacists who practice in medical home models alongside our physician colleagues. I'm testifying today on behalf of the Colorado Pharmacist Society. The National Center for Health Workforce Analysis projects a shortage of 70,610 primary care physicians by 2038. Pharmacists are well-trained to provide primary care services involving medication management. All pharmacists have doctoral degrees and many like those at CU have additional postdoctoral training CU pharmacists see patients directly to manage their medications for hypertension diabetes and other conditions Our doctors appreciate and rely upon this support in their very busy practices as this frees them up to do more complex care activities. Chronic disease management by pharmacists is cost effective and helps more patients reach therapeutic goals sooner. Most of the pharmacists in our system came about due to a federal Medicare payment program that was terminated last year. Our team collaborated with our medical colleagues to build a billing model to sustain these services, but it is limited. Right now they can only bill directly for certain services provided to Medicaid patients, not patients insured through commercial plans. Primary care is unavailable in some parts of our state, and primary care providers are overworked in others, resulting in a lot of unmet needs in our Colorado population. Take high blood pressure. Inadequately treated high blood pressure is a silent killer and key risk factor for heart disease, stroke, kidney failure, and cognitive decline. Nearly half of adults in our country, and I dare say probably in this room, have hypertension, but only one in four are controlled. This bill enables pharmacists to provide accessible care for high blood pressure screening or medication management when it's already diagnosed. This will not replace medical care by physicians, which already exists, should continue, but it will expand access to care, improves, and even save patients' lives. Thank you for your time and consideration.
Thank you so much for your testimony. We'll move online to Dr. Moore.
Hi, good morning, everyone. I think it's good afternoon now. Thank you for the opportunity to testify today. My name is Gina Moore. I am a pharmacist and pharmacy law professor at the University of Colorado School of Pharmacy, but I'm here today as legislative chair for the Colorado Pharmacists Society. Specifically, I'm here to speak on training of pharmacy students and what pharmacists are prepared to do upon graduation. First, all pharmacy students in the U.S. graduate with a doctor of pharmacy degree, which is a doctoral level professional degree. Pharmacists are extensively trained on optimal drug selection and drug dosage for all patients. Weight-based dosing for pediatric patients is something our students must do in their very first semester of school. No student will progress past the first semester unless they can safely counsel on acetaminophen dosing for a child based on weight. Our training and dosage adjustments only increases as all pharmacists must be able to recognize appropriate dosage adjustments in patients with kidney and liver disease. I'd be happy to share with the committee pharmacist training in pharmacokinetics in which we use different algebraic models, but I'm sure that's probably not something you're interested today. But the point is weight-based dosing is easy and what we do every day. We are responsible for ensuring appropriate dose, regardless of who prescribes the medications. Students also receive training on test and treat, basic physical assessment and technique on both obtaining nasal and throat swabs. A 2023 study published in the Journal of Antimicrobial Chemotherapy, a leading infectious disease journal, demonstrated the success of sore throat test and treat services in the UK, in which 11,000-plus consultations in patients six and older. Pharmacists were able to manage 91 of the consultations and referred approximately 9 of patients to primary care and only less than 0 to the emergency department Antibiotic prescribing frequency was lower than that in primary care The authors concluded the service could substantially reduce workload from the busy primary care office and emergency departments. I see I'm running short on time, so I will urge you to vote yes. Happy to
answer additional questions about our training. Thank you so much. We'll move on to Dr. Joseph
Pulling. Thank you, Madam Chair, members of the committee. I am super grateful for the opportunity to speak today. My name is Joseph Pulling. I'm a pharmacy owner with Good Day Pharmacy here in Colorado. We own and operate community pharmacies across the state. And I want to tell you what this bill looks like from where we stand, which is behind the pharmacy counter face-to-face with families who just need help. As you've been learning right now under current law, we can test a child of any age for strep flu, COVID, but if that test comes back positive and the child is under 12, we have to look that parent in the eye and say, I know what's wrong with your child, but I can't treat them. You'll need to make another appointment or go elsewhere. That parent now has to leave, end up in urgent care, you know, get fit in or squeezed in at a local clinic, or worse, go to an ER, something that we already have identified and are trained to handle. So this bill fixes that without expanding our scope of practice. And here's what I want you to know about how we at Good Day Pharmacy would approach this. We do see this as a collaboration with local providers who we work very closely with currently. It's not competition. When providers are overbooked or patients can't get in, we step in and can send a full report back through fax or an e-care plan. That would be the test results, our assessment, the prescription we filled in-house. And truthfully, we're not marketing or advertising for this. We're not trying to replace anyone. We're just trying to take care of people who are already standing in front of us. At a time when Colorado is facing a real budget pressure and cuts to programs like Medicaid, this bill gives families a lower cost option that's already right in their community. So we urge a yes or an aye vote. Thank you for your time and happy to answer any questions.
Thank you so much. We'll move on to Dr. Kim Ward.
Good afternoon, Madam Chair and members of the committee. Thank you for the opportunity to testify today. My name is Kim Ward. I'm the director of pharmacy for King Soopers and City Market Pharmacies. We have 151 pharmacy locations across Colorado and testifying today on behalf of the retail council, who represents over 800 pharmacies and 8,000 pharmacists testifying in support of the bill today. Also here to show support for the Colorado Pharmacist Society on this great bill that they've drafted and the importance of the components therein to increase access and support modernization and reimbursement changes that we need in a very challenging industry. As the committee was coming to order today, you know, just thinking about it, I'm a pharmacist and I get the chance to do that, not on the bench every day, but representing our everyday pharmacists. But here in our office today, someone wasn't feeling well, and I got the chance to run down there right before this, take their blood pressure, identify a hypertensive crisis, and get them on the way to higher level care. So pharmacists step in every day when patients come to us and ask for help, and referral of symptoms is an important thing that we do every day, like just today. Specific to this bill, the minor self-limiting conditions that we're testing for that are CLIA wave testing completely agree that pharmacists, this is something that we can do. We get questions from Coloradans, from parents about testing their children. We triage questions around self-care and OTC needs every day. And our pharmacists are very well-trained and equipped to do this. And again, it increases access Our pharmacies these patients and customers are already coming into our stores us being a grocery organization They already coming to us We seeing families of multiple age children with questions We open nights weekends and most holidays So that access is really important We also provide an affordable cost Our costs are lower than they're publicly available. Happy to talk more, but our costs are less than the urgent care. So it increases cost access. And of course, it's free to ask pharmacists questions. That makes is so accessible. We are seeing then moving on to tech product verification. This is something we do in other states at Kroger, being part of the Kroger family, and this does improve morale of technicians, retention, creates great jobs for pharmacy techs, and provides some pharmacy flexibility in how we run a very complex business. With reimbursement, we have to reimburse pharmacies. I don't know for the committee members, if your pharmacy has closed or you've seen a pharmacy in your district close, that's because this industry is so challenging and we need reimbursement relief.
So thank you. And I ask for your support. Thank you so much for your testimony. We'll move on to Dr. Crow.
Hi, good afternoon, Madam Chair and members of the committee. Thank you so much for the opportunity to testify today. My name is Andrea Crow and I am a pharmacy manager practicing at City Market Pharmacy in Carbondale, Colorado. In my community, like many other small towns in Colorado, access to health care is pretty limited. To put it in perspective, we are the only pharmacy in town, and there is a shortage of primary care practitioners, especially for children. Many of my patients are uninsured. Many are Spanish-speaking, which can make navigating the health care system especially challenging. For them, the pharmacy is often the most accessible and sometimes, realistically, the only point of care. In my pharmacy, I already provide testing and treatment for strep throat, COVID-19, and influenza for patients who meet current eligibility requirements. That includes being over the age of 12 and not presenting with severe symptoms or complex medical conditions. These are services that I have been trained to deliver safely and effectively, and they allow the patients to get care quickly. And like Kim said, we're open seven days a week, including nights and weekends. Recently, I had a 10-year-old girl come in with her mother later in the evening. They were Spanish-speaking, had no insurance. This family had been in before for medications, and they were really familiar with our pharmacists and staff members. The daughter had symptoms highly suggestive of strep throat. She had fever, sore throat, and swollen lymph nodes, and I was fully prepared to test and treat her. But I had to turn this patient away, not because of any safety issues, not because I had a lack of training, simply because of her age. For this family, that meant seeking care elsewhere. The only option for them at this time of day was the urgent care located in the next town over. This meant that the family would likely face delays, added costs, and language barriers in a less familiar and comfortable setting. Because of these barriers, I do not have good faith that the child was able to get timely care. According to the oath of a pharmacist, one of our primary goals is to facilitate relief of suffering in all of our patients. And I felt that by refusing care when we're trained to treat these patients, we were impeding care and perpetuating their suffering.
Thank you for your time and consideration. Thank you for your testimony. We'll move on to Dr. Kai Davis.
Kyle Davis, Thank you, Madam Chair committee. Kyle Davis, I am Kai Davis, I'm the pharmacist at Harris Pharmacy in Rocky Ford, Colorado. I'm the only pharmacist at the only pharmacy in town. My rep winner mentioned pharmacies in his district, that's me. We also have Kiowa Drug Pharmacy in Eads, Colorado. Eads is the only pharmacy in town. There's one clinic in town. There's also a hospital with an emergency room. I want you to put yourself in the shoes of a parent with a six-year-old. Your kid's sent home from school with a fever, and you call the clinic, and they're booked up until Monday. That's too late to do you any good. You can drive two hours to the nearest urgent care. There's a pediatrician an hour and a half away, but they're booked up too. you could go to the ER. That's an option, but you know that's really expensive, and it's probably overkill for your kid that doesn't seem to be that sick. They aren't life threatening. This isn't an emergency. So what do you do? From decades of experience, I can tell you. Some will go without care. They might come in and ask me for a cough syrup recommendation. They might go to the dollar store for that and get no medical evaluation at all. Some will use the ER. Some increasingly will use telehealth. I get dozens of prescriptions from a doctor based in Florida after a six-minute consult over Zoom with a patient they've never met before. Did they check her temperature? Did they check her pulse? Did they do a swab and run a test? Of course they didn't. It's over Zoom. They ask some questions and let an algorithm do the decision and prescribe. I'm not interested in competing with my clinic in town. They're my partners in care. When we thought about starting this test to treat program, we reached out to them and said, hey, is this stepping on your toes? And they said, we are so sick of staying past seven o'clock at night to try and squeeze in these kids. Please take on this burden is not something we're looking to compete with them for. We're trying to fill in the gaps to serve our communities that do not have access to enough care. We want to add additional options for this parent that I just asked you to step in the shoes of. So paying pharmacies for this service is cheaper than emergency visits and safer than telehealth. Thank you for your time and urge you to vote yes.
Thank you so much for your testimony. With that, we'll turn it over to the committee. Questions from the committee. Representative Johnson.
Thank you, Madam Chair.
My question is to Dr. Davis.
House District 63 is a lot like your area. We have one urgent care in seven counties, and that has limited hours. We are backlogged. We don't have enough, you know, child doctors. so can you speak to the capacity of pharmacies to provide high quality care kind of continuing what you were already saying very concerned with when some of my folks get into that urgent care they can treat one issue give one medication and they have to head out or go to the ER can you speak to the volume that you can do as a pharmacist to help with our children Dr. Davis yes thank you for the question the volume the sky is kind of the limit If we have the ability, especially to get paid for these services, we can take on extra staff to do that. So we are here to help our patients. That's always our priority. And we will, you know, you don't get to be a pharmacy working in a rural community unless you're willing to take on problems that need to be solved and find creative ways to solve them. So that is what we do every day in a million different ways. We can help fill those gaps. We're here in those communities now testing older kids to add to the five to 12 year old to our bucket isn't that big of a burden. My wife is a school nurse. And believe me when I tell you that she wants me to be able to do this constantly sending kids home and they need to get in to be seen Maybe their brother or sister already been diagnosed with the flu These are relatively straightforward things to do but there just isn the capacity to do them through the legal mechanisms
Vice Chair Leader. Thank you, Madam Chair, and I do have two questions, and whoever wants to take it. But so since independent test and treat was put into place in 2021, how many children in the ages of 12 to 18 have been cared for? Whoever wants to take that. Dr. Davis wants to take it or. Dr. Zavani.
Thank you, Madam Chair. I can give it a try. I don't know that we have any way of having that data. You know, you could pull prescriptions, I guess, from maybe the all payer claims database or something like that. And I would welcome any of the panelists to step in on this question. But there's nothing in the state that's tracking that. So it would be anecdotal.
Vice Chair Leader? Oh, I'm sorry. Someone had that. Dr. Ward.
Thank you. I believe I could contribute to this question. I don't have the total number of tests to share today, but I can share percentage wise that between the ages of 12 and 17, 16% of our flu strep and COVID tests are done in that 12 to 17, 16%. And then 18 to 26-year-olds represent 15% of our tests. Their remainder would be adults older than that. So just to give you a little bit of a picture of what we're seeing.
Vice Chair Leader. Yes, thank you. So what does the current test and treat look like here in Colorado? So what's the process? Is it a self-pay? Is it billed through insurance? and then also are appointments required or DTIC walk-ins?
I would like to answer that question. Dr. Sudvarni? Others? I think all of us could. The current, there's all models, right? So wherever that practice setting decides, they can decide if it's a fee for service, right, which a lot of it can be because it's, you know, it's uninsured. As we've heard from several of these people, they don't have insurance. we are able to bill Medicaid for these services which we're very grateful for so Medicaid patients can access these services largely the commercial payment laws are not robust enough another point of this bill to be able to reliably do that and then I would say and any of you can correct me on this one there are appointments available but not required so they can if it's convenient for a patient to say oh, I'd like to come at 2 o'clock today, I can sign up for that. But if they don't want to, then they can walk in and have these services.
Representative McCormick. Thank you, Madam Chair. I think my question is for Dr. Moore. You had mentioned about the training that pharmacy students go through and the pharmacology classes that they take. are there also classes or training around diagnosing, or is it specifically in response to interpreting a test and then knowing what to treat for that particular test? I just wanted to hear a little bit more about the training around diagnosing.
Who is that? Dr. Moore. Dr. Moore. Dr. Moore. Yeah. Hi. Thank you, Madam Chair. Thank you for the question. Yeah, so I think there was multiple parts to your question. But all of our pharmacy students get basic assessment training, blood pressure, respiratory rate, pulse. In terms of some of the practice readiness and I think Dr Ward and others can probably speak to the specific training but the test and treat services are fairly straightforward Looking in the throat, taking a swab of the throat, making sure that the patient's stable, making sure that they're also looking at temperature just to make sure it's not abnormally high. those are all really pretty basic things that they're trained to do and then we know we know what to refer so if somebody has a prolonged fever and dr ward can probably speak to their specific protocols but generally greater than 101 or 102 for a couple days they're going to get referred or if they're having difficulty swallowing or if they're having trouble breathing those are folks that are unstable. Those are the folks that we're going to refer. But we're very capable of assessing and treating patients that are stable, that present with lower fever, very sore throat, taking a swab. And those tests are quite simple to run in determining whether or not they test positive. Before you even run a test, you're probably going to make sure that they even meet clinical criteria to even conduct the test to begin with. So I think it's very similar. I'm a mom of three kids and have lots of experience with that myself and assessing and knowing when they need to be treated. Representative Ryden. Oh, sorry, I didn't interrupt. Did I answer your question? Sorry. Yes, I think Representative McCormick is nodding.
Representative Ryden. Thank you, Madam Chair. A couple of questions. My first question is for Dr. Davis. Thank you for taking time out of your day to day. And I know you are part of Representative Winner's district. Can you talk to me a little bit about just the number of pediatricians that are actually in the district? And I mean, I think you said that they were, for the most part, in support of this. So I would love to hear that conversation. And when this law went into place back in 2022, I actually thought for 12 and above, Just anecdotally, how often are you doing test and treat for that 12 and above? Dr. Davis.
Yes, thank you for the question. 47 is a big district geographically. It covers a lot, a lot of land. I'm not entirely sure where those borders are, but I believe there are two pediatricians who practice in that each about an hour apart. and you can go an hour plus either way and still be in District 47. I know that both of those pediatricians work shorter hours than my pharmacy is open by a considerable amount. So the availability of those pediatricians is just never going to be able to match what the pharmacies are able to offer. the 12 and up. I will say I don't have numbers on how many how many tests to treat we do in that. I just I didn't pull anything like that, but it is primarily children. You know, I would say our numbers probably reflect what what Kim Ward said, where it's primarily young adults and and children. uh i get a lot of interest in in testing the 5 to 12 range uh school-aged children a lot of referrals from from school nurses and that kind of thing to try and get uh a test a lot when we get into high school we see a lot of they want to get a test that that negative test that positive figure out what they doing so that they cleared to play sports again uh whether or not they get treatment they want to get a test that negative test that positive figure out what they doing so that they cleared to play sports again whether or not they get treated they want to get that test So there some of that that goes into play too But we do always try to cooperate I want to send people to their primary care providers. That's our primary goal to get them into their primary care provider. But that's just not always an option. There aren't enough openings, especially when a small community gets slammed with flu, it gets out of control real quick.
Representative Wright. Thank you, Madam Chair. Kind of a follow-up question to that. But I'm trying to put this in perspective. How much test and treat you actually do currently? Is it like one a week, 10 a week?
During cold and flu season, it's probably in the a couple a week for me. I would say I am probably lower in it than some because of insurance pricing. I am strictly cash pay. I don't have any insurance contracts. If I did, I know it would be higher.
Cost is a deterrent on these.
Representative Stewart.
This bill is including insurance contracting rules. A quick follow-up. Representative Wright. Thank you. This was actually just another question, and this could be for anybody. I'm curious if when you're testing and treating, if there are times when the individual tests positive, but the patient doesn't necessarily want the treatment, and if there's a consultative process that you go through with the patient. And what I'm getting at is we know sometimes that antibiotics and things like that are actually not, it's kind of optional. And I know doctors often are like, hey, you know, maybe this will shorten the lifespan of this illness 12 hours or, you know, three, two days if you want to give it a try. but they also give that advice that antibiotics can also do damage as well. So help me understand that. Dr. Weiss. Yeah, that's a great question. So in terms of the flu, I have turned away a patient. That medication is best taken within 48 hours if you test positive for the flu. So I have turned away a patient before they even paid any assessment fee. our assessment fees are $49 cash pay we do not take insurance at the moment because it's really difficult to get reimbursement for it so we just do cash pay so they said I before they even filled out any form they said they had had the flu like symptoms for 72 hours so I told them sorry cannot give you this treatment at this time as far as antibiotics per strep everyone that has tested positive has been in and out the door with the assessment within 15 minutes with the medication in hand and taking the medication. No issues. They're at the pharmacy because they want the medication. Dr. Ward. Yeah, I'd be happy to add to the question there. We have heard of some patients who sometimes they just want to know the result of the test for their own well-being, just to know, or to let their employer know, hey, I do in fact to have COVID and I'm going to stay home from work. Some do take the treatment, some choose not to, but having that discussion around the selection of medications and the likely efficacy based on a timeframe, those are conversations we have with patients today when they bring in a written prescription or we receive a prescription electronically from their provider. So we're well-versed in having those conversations once we get to that point of the clinical visit of, okay, now it's positive. What would you like to do with treatment? And then we talk through that. So we have seen many do want to get the treatment. That's why they came to us, but some have reasons why they choose not to. And I'd be happy to talk more about our training and our visit process if anyone's interested. Representative Stewart. Thank you, Madam Chair. This question is for Dr. Dr. Zadvarni, I was hoping you could speak a little bit to the policy that we see in other states for those age ranges. So, you know, what is it like for states that do 5 plus? Dr. Zadvarni. Thank you, Madam Chair. Thanks, Rep. Stewart. So we know there's 21 states that have zero age limits, right? And I think for the most part we all agree that statute is important to have some details in, but it's also important to leave that policy to be implemented in protocols in practice settings. So 21 states have no age limits whatsoever, and then five states have age limits, and that includes us. The other states are all three and above or five and above for those five states that do have age limits. Can I ask a follow-up quick on that? So, sorry, the states that don't have age limits, do they have the same test and treat protocols that Colorado does? Or does that vary by state? Dr. Zavrani. Thank you, Madam Chair. It varies, right? And so right now we don't have what we think of as one protocol for our state. Those protocols are developed by practice sites. So your Kroger will have a protocol. Your Clear Springs will have their protocol. and other states do the same thing. Arkansas has a statewide protocol, right? So it just depends on the state whether they approach it as a one-size-fits-all protocol or if they allow each individual practice setting to develop a protocol. But nobody's out there practicing without protocols, right? I mean, even, and you'll hear from some of the other independents, it takes a lot of time for them to use their skills to, you know, develop their protocols, right they want to make sure it's completely evidence-based they're reviewing all the literature the guidelines but everybody has a protocol it's not just practicing kind of willy-nilly so thank you uh just another follow-up to that so of the 20 states that you mentioned that are that have no so current practice in colorado is that the same for those 20 states that also have no age restriction. Thank you, Madam Chair. In those states, statutorily, zero age limit. So they could test and treat any age. They could then adopt policies that were more restrictive. In Colorado, it's statutory that we can't test and treat anyone under 12. So then our policies have to be at that age and above. We can't go below that. Am I answering your question? I think so. I didn't even call you out. Sorry, doctors. No, that's I it's always confusing when I ask questions. I think, yeah, just trying to get clarity on. Is it 20 states do a version of this or is it 20 states actually do what you are proposing in this bill? 20 states are doing this for no like they they don't have a statutory age limit so 20 states their legislative body has passed that they can test and treat at any age level and then they take that broad authority and they develop their protocols right so they still may have protocols that are five and up or three and up on a practice basis or a you know a site specific basis but the state has not imposed any of those restrictions on them. If that makes sense. And the other five do, sorry. So there are three and up and five and up in a few of those states. And in those states, they have to. But there no uniform protocol I think that kind of what you getting at too There no uniform protocol in most states Okay Thank you We are way over time on this panel and we have lots of other ones Oh, do you want to? No. Are you sure? We have several other pharmacists, if you're so fair. Okay. If you change your mind. Okay, wonderful. Thank you all so much for testifying. Thank you. Appreciate your participation today. We'll move. We're going to alternate, so we'll move to opponents.
We'll start with Dr. David Keller, Dr. Laura Melenco, Dr. Cassie Littler, and Isabel Hinshaw. Okay, we'll start from my left to my right. If you can introduce yourself and the organization you represent, you have two minutes.
Thank you, Madam Chair and members of the committee. My name is Isabel Hinshaw. I am the Director of Government Relations at the Colorado Academy of Family Physicians. I am speaking today on behalf of our President, Dr. Cori Lyon, in respectful opposition to HB 261336. First, I want to acknowledge and appreciate the sponsor's intent. Expanding access to care for patients across Colorado is a goal we all share, and we value the important role pharmacists play in accessibility as well as being a trusted member of our healthcare team. However, we do have concerns with removing the age restriction in the test and treat model to include children under the age of 12. Caring for pediatric patients is fundamentally different from treating adults. Children are not simply small adults. Their treatment requires specialized training, nuanced clinical judgment, and a comprehensive understanding of their medical history. Family physicians and pediatricians spend years training to specially care for children. That training emphasizes not only diagnosis and treatment, but also recognizing subtle signs, more serious conditions, and understanding how treatments may vary in their effect on children over time. Equally important is access to patients' full medical records. Safe and appropriate treatment decisions rely on knowing a child's history, including prior illnesses, medications, allergies, and underlying conditions. In most cases, pharmacists do not have access to this complete information, which can increase the risk of fragmented care and unattended consequences. We deeply value our physician colleagues and the care they provide. Our concern is not about their commitment or expertise, but about ensuring the care for our youngest and most vulnerable patients remains comprehensive, coordinated, and safe. For those reasons, we respectfully ask the committee to oppose HB 26-1336. Thank you for your time and consideration. Thank you so much for your testimony. Please proceed. The little tiny one. The little one. Thank you. Hi. Thank you, Madam Chair, and thank you committee members. My name is Dr. Cassie Littler, and on behalf of over 800 pediatricians across the state, I represent AAP Colorado, and I ask you to oppose House Bill 1336. As a pediatrician who grew up in Sterling in Northeast Colorado, in Representative Johnson's district, who practiced on the Western slope for over 12 years and currently work at the federally qualified health center and
representative Gilchrist district. I know firsthand about the dire need for access to care
across our whole state. I know that these patients personally, I have navigated the complexities of our healthcare system alongside my neighbors, my community, and my family. We all agree, access must improve. But how we improve it really matters. Policy should strengthen and integrated pediatric care not fragmented As you will hear a sore throat is often just the surface of a more complex clinical picture Whether I working in primary care clinic or working weekend urgent care shift like I did on Sunday from 10 to 7 for extended hours in the medical home, I have treated children whose initial symptoms mass severe conditions, such as a retropharyngeal abscess or a deep tissue abscess that requires immediate hospitalization, IV antibiotics, and surgical drainage. Others present with viral illnesses that should not receive antibiotics at all or with conditions like Kawasaki disease where a misdiagnosis can lead to lifelong heart complications. In a fragmented care system, these diagnoses are really much easier to miss. Equally concerning is what this does to the pediatric medical home. Pediatric practices work to improve care, reserving same-day sick visits, and all designed to keep care connected and comprehensive. But as more care is carved out into disconnected settings, pediatric practices become less sustainable. We are already seeing pediatric shortages across Colorado, especially in rural and underserved communities. And further fragmentation accelerates practice closures and weakens the very system that children rely on. We could not ignore the broader context. This is another example of underinvestment in children's health care. And I ask for you to oppose this bill. Thank you. Thank you so much for your testimony. Please proceed. Hi, I'm Dr. Laura Melnico, representing the American Academy of Pediatrics Colorado chapter. I want to thank Madam Chair and the committee for allowing me to speak in opposition to this bill. I'm a retired pediatrician. I provided primary care for 30 years in Trinidad, Walsenburg, and Denver. The first rule of medicine is to do no harm, and I'm concerned that this test and treat plan could cause harm to Colorado children. A diagnostic test does not alone make a diagnosis. A medical history and physical exam are also crucial, and these, along with vital signs, which vary by age and can be very difficult to obtain and interpret in young children, can signal a more serious disease. Diagnostic tests are not always accurate. A false positive test can lead to unnecessary treatment, and that could cause undesirable side effects and contribute to antibiotic resistance. A positive test can occur when there are other secondary or serious complications present. Again, the history and physical could reveal these unanticipated or subtle findings, an abscess, pneumonia, heart complications, or sepsis. There are conditions that would require immediate hospitalization and treatment. Will pharmacists need to have malpractice insurance to protect against possible improper or misdiagnoses? Children are best treated in a setting where their medical history is known. Visits for acute illness can be an opportunity to follow up on chronic medical conditions like asthma and diabetes. the test-and-treat model would disrupt that primary care. Pharmacists are an important part of the medical team. They provide education about medications and give vaccinations. But because of the diagnostic implications and safety concerns, although convenient, this test-and-treat would not benefit the health of children in Colorado. I urge you to vote against. Thank you. Thank you. Please proceed. that worked hi my name is david keller i'm a pediatrician speaking on behalf of the american academy of pediatrics colorado chapter also in opposition to hb 1336 i a pl 43 in our jargon that means i in my 43 year the year 33rd year of pediatric training And I say that because caring for children is hardly ever simple and I constantly learning in my role as a primary care pediatrician in Aurora This bill's expansion to the test and treat model at the pharmacy counter for children under 12 raises serious concerns about pediatric safety. While pharmacy-based testing may improve convenience, the evidence does not support independent test and treat models for children under 12. To be clear, the reason no adverse events have been reported is not that they've not occurred. It's that there's no surveillance infrastructure that's been built to try to find them. That's a failure of data systems, not a finding of safety. The committee should not interpret silence on this as reassurance. Absence of evidence is not evidence of absence. We understand that the needs of busy families are they're juggling work and school schedules, and we know that Colorado faces health care workforce shortages across the state. However, the changes in this bill threaten to replace high-quality pediatric care with a simplified model that compromises patient safety, diagnostic accuracy, and continuity of care for children. When I see my patients coming in with various symptoms, I perform a physical exam, ears, throat, lungs. maybe the symptoms require a test, but I do not rely on a test alone when determining the best course of treatment, which most of the time is chicken soup, not a prescription medication. Many childhood illnesses like sore throats are viral, not bacterial. Relying on testing alone increases the rate of false positives and can lead to unnecessary antibiotic use with broader implications for antimicrobial resistance and patient safety. We can all agree that convenience matters, but children deserve the same high standard of care regardless of setting. Pediatric care must be clinically appropriate and never come at the expense of safety. I respectfully ask that you protect Colorado's children by removing the provision in HB 1336 affecting those under age 12 and ensuring continuity of care through coordination with the medical home. Thank you so much for your testimony.
Questions from the committee?
Representative Fryden. Thank you, Madam Chair. I think this is for the folks from the American Academy of Pediatrics, so maybe Dr. Keller. And I think you hinted to this a little bit when you were talking about there's no surveillance data. But we know that this has gone live in 20 other states where they don't have this age limit. And, I mean, has there been stuff that has come up in those states? Dr. Keller. Well, thank you for the question. It's a really good one. And part of the problem is that the way we do surveillance in this country is state-specific and not coordinated across states or within states. So, for example, in our state, the best way to look for surveillance data would be our all-payer claims database. But as we heard earlier, many of these services are provided on a cash-only basis and it's not collected in our all-payer claims database. Similarly, as far as I'm aware, the pharmacies do not share their records with us, meaning we have, for example, in my clinic, we have an extensive medical record that pulls in records through Contexture, which is our statewide health information exchange. But none of this data gets fed into that system. So, again, as far as I'm aware, we're not able to track it, and I've not found any place in this country that's been able to. If you look internationally, probably the best source of data is Britain. Britain has had a program, a pilot program for putting for test and treat at the pharmacy level. And their report that was issued, I think, about a year ago was inconclusive as to whether... test and treat was beneficial to their patients or not. And they actually do have a unified system that collects data. So that's as good as we've gotten so far. Can I ask a follow-up for the panel, not just Dr. Keller, but on the 20 states, I still am not clear if there is a difference sort of in what we're proposing in this bill to the other 20 states that are doing a version of this. So could you talk a little bit about sort of, it's my understanding that test and treat in many states don't grant independent authority, and so they have collaborative agreements. So maybe if anyone could talk a little bit about what a collaborative agreement looks like. Dr. Keller. Again, another good question. I haven't spent a lot of time studying this. On the weekend was a look through the literature. The last time I frankly looked through the strep throat literature was 40 years ago when I was a fellow. But going through the updates, there's, I found some references to say that of the 20, and this paper reported 20, I gather there's another one. So we're up to 21 of the 20 states that allow test and treat, eight of them allow test and treat independently. And the rest require some form of collaborative agreement. I haven't dug down into all the state laws to find out what sort of collaborative agreement that those have. I'd be interested if my pharmaceutical colleagues have done so. Ms. Hentia? I can add just a little bit more. Our federal partners had some information on the different states. There is one other state that does have an age limit. Iowa does not allow test and treat under the age of six. There are some states that only allow test and treat during public health emergencies and other restrictions. So each state is pretty unique. I would follow Dr. Keller's other specifics. Representative Wook. Thank you, Madam Chair. So, I mean, clearly there's a concern that pharmacists will misdiagnose, and this is for anyone, actually. I mean, do doctors not ever misdiagnose? Dr. Keller. Well, thank you. I would say, you know, in a clinical context, when we're looking at a patient and say the strep test is positive, but I'm looking at a tonsillar abscess and I know that they're having a fever and they can't open their mouth and they can't turn their neck. I know that I don't give them low dose amoxicillin and send them home. I should admit them to the hospital and give them IV antibiotics. And so using a test as part of a diagnosis and a clinical picture is really important. I don't know if that answers the question, but. Representative. Oh yeah, Representative Luke. Thank you, Madam Chair. maybe there's more of a comment, but I'll just make it now since we're talking about this. I feel that parents are going to be tuned in to their children, and maybe some of you have children. I don't know, but I guess I just don't understand. To me, the parents are going to know who they need to take their kids to if there's something a little more serious, but you're the doctor and may respectfully disagree, but yeah, I just don't understand why if there's something more major and they can't turn their head, they're going to go to a pharmacist. But anyway, not necessarily it's something you need to answer unless you want to. Dr. Keller. I'll take a stab at it. Yeah, we're not perfect. I mean, and I don't think anyone would ever claim perfection in these things. I think that, as you say, I have seen parents who are really good at assessing their children. I seen parents who need a lot of help in assessing their children So I think there a spectrum of things And the important thing about the medical home is we want to establish a place where you comfortable coming in and asking us the question. And we don't want there to be any barriers to that. So our biggest concern with the fragmentation of care, particularly in fragmenting care in such a way, we're putting a lot of energy into this whole electronic health record thing so that we can have access to the whole health record. And this is setting it up so that we're not going to. I won't be able to tell. I can't tell if our friends at the pharmacy did a strep test on somebody. I can have a parent tell me that. But again, then they begin into this whole game of telephone where we're not sure the information is being transmitted clearly. So we're worried about the fragmentation that would result. Representative Stewart. Thank you Madam Chair. I have two questions but I'll make one really quick. Out of curiosity we talked about liability and I'm wondering if any of you know whether pharmacists carry liability insurance. I see the panel nodding or shaking their heads. Okay. Do we have maybe a panel for a question? My second question is around this information. I believe we've been doing test and treat in the state of Colorado on 12 plus for the last few years. Have there been any complaints with DORA or any regulatory agency around misdiagnosis? Great question. I think we don't have a mechanism to look at that data. So if I have a patient that comes in who has seen a pharmacist and had a test done and had an amoxicillin reaction, I don't know where to report that. I don't have any way to say this amoxicillin reaction because this kid has mono is related to the test and treat that happened at the pharmacy. So there's no mechanism for me to report that data currently. So I don't think we know. Sorry, I'm going in order of folks that asked to ask questions. So Representative Johnson.
Thank you.
And I have two questions because we're talking about access. How is it fair for those who live in rural areas, their children, when we have counties without hospitals? We don't have ERs. We don't have urgent cares. Our home is the pharmacy. I can say without doubt that the pharmacies I've known, mine, when I had complex issues, knows my medical record better than the providers I had. So to say that they don't know the health in rural areas is disingenuous to the work they do. But my question is, how can we tell parents that they don't have access to care, and then they go home and they get worse? As a former EMS, I've had calls that something that could have been treated from a simple diagnosis moves to the lungs. It moves to something worse. We now have kiddos who are scared in ERs. ERs are a scary place, and they're expensive. If they could get the first stop of care and we could treat them, is that not what we should be doing for our children?
So let's just also make sure we're not impugning, talking about intentions of witnesses, please.
Would anyone like to answer that question? Dr. Littler. I would just say that this, you know, I agree, access to care is really important. And I think the chronic underinvestment in pediatric care across the state is really, you know, the cause of all of this. And so if we could, you know, better invest in our kids, better invest in the pediatric medical home, then I think that this wouldn't be an issue. And so making sure that we invest in the workforce making sure that we invest in kids making sure that we invest in the practices that are doing the care currently makes the most difference Representative Johnson Thank you In trying to figure out, you know, investing means years down the road. We have many kids who get sick tomorrow or in the next week. So that's scary for my rural folks that they're not going to get the care they need now while we work on the future. My question though on HIPAA is it really is up to the parents on what they share. If they sign a release when they see a pharmacist, that information can be added to the records, just as if they went to a doctor and say, I don't want my information shared out of network. That is health care information that can be shared. I know parents who share their information from pharmacy to clinics and clinics to pharmacy. So, you know, how do we address that saying, you know, because I've seen parents do say, I don't want my records to be shared. I don't sign that form for my kid to go and travel with them. I would like to answer that question. Anyone have? I'm not quite sure I understand. I'm going to say thank you for the question, but I'm not sure I understand it. Currently, the only information that I reliably get from a pharmacy is when a question is being asked. I'll get a phone call from the pharmacist saying, is this the prescription you meant to write? Did you write a dosing correctly? We have a discussion. And I guess I wanted to put that out there is to say, please, pharmacists are my best friends. I mean, I work with pharmacists all the time and they are extremely good at what they do. So I have full respect for that piece of what they're doing. What I'm concerned about is the extension of what they do into something that is not something that historically they've done. So that's one piece. The second piece is I'm not sure how we can get information from pharmacies regarding testing and treating because there's no vehicle for doing that at the present time. You can sign the release, but the pharmacists, as far as, I mean, the pharmacists could fax us a note, I suppose. I've just never gotten one, so I don't know that that's possible. I'd be interested to hear from our pharmacy colleagues if that is. We'll do one quick follow-up. We are over time already on this panel and have three additional questions.
So one quick follow-up.
I just want to make sure we get to that. Quick question, Sash, comment is we do have, you know, the state that keeps track of vaccinations. If I go to my pharmacy and get a flu shot, that's updated to my primary. It's updated when I travel. When I got my travel records, it updates to the state system. That updates in your health records. Does it say it's not being shared? No, that information is being shared through SIS, through the statewide immunization database. And that information is shared. but information about tests are not shared through that system. Sorry, Vice Chair Leader. Thank you, Madam Chair. So I don't know if you'll be able to answer this based on what I've heard already, but mine is specific to children. So are you aware of any studies that specifically look at the safety and efficacy of tests that treat, test or treat for children? Who would like to answer that question? Dr. Keller? I'll take a step. I'm not aware of any specific studies that have looked at that. As I mentioned, the big studies that were done in England tended to look at the older population and had a very small number of children within it. So it's not clear how accurate or whether that was the right study to be looking at. Thank you. Representative Wright. Thank you. In one of the scenarios that you mentioned, I just want clarity. You said that a kid had shown up with mono. Has that happened before that they ended up having mono but that they were tested or they took antibiotics and were tested for that at a by a pharmacist Well I can say by a pharmacist but I would say that this is the most common thing. And you'll probably hear from some of my colleagues coming up, how common this is. Kids come in with a sore throat, swollen lymph nodes, fever, and look just like having strep. You do a strep test, 20% of kids carry strep in their throat, but it ends up that these patients actually have mono. They take the antibiotic and then usually, you know, a few days later they get an amoxicillin rash because we're not really treating the strep throat, you know, it's the mono that's causing the issue. And so when you're able to see a patient in your practice and you're doing a full examination, you can, you know, check the spleen, do a full physical exam, make sure that you're not missing those other signs of mononucleosis. Representative Bradfield. Thank you, Madam Chair. I want to thank the four of you very much for being here today. Which ones of you feel that your practice is in an urban setting? Okay, how about a suburban setting? Sorry, real quick, so Dr. Littler and Dr. Keller raised their hands, just for the record for those who. Representative Bradfield.
Suburban. Okay, and a rural. Dr. Laila. Can I just say that I worked, I owned a practice in a rural area for almost 12 years. So, both. As did I before moving out here. I currently practice in an urban setting. I used to practice in a rural setting. I'm retired, but in both rural and urban. Okay. Time has expired for this panel. Thank you so much for your participation. We appreciate you being here today. We'll bring up the next proponent panel, Dr. Kristen Holmes, Dr. Powell Kimis, Dr. Kelsey Schwander, Dr. Angelson. Looks like maybe some of those folks are online. Proponents. Yeah, to your next question. And then we'll also bring up Dr. Ruth Olson and Dr. Nikki Price. Okay. You can introduce yourself. I'll start from my left to my right. If you can introduce yourself, the organization you represent. You have two minutes. my name is Kristen Holmes and I've been owned and been a pharmacist at Capitol Heights Pharmacy in the Congress Park area of Denver for the past 13 years I apologize ahead of time if this is a little fragmented because I actually kind of stripped a lot of what I was saying to try to address some of the questions and concerns that were in the last panel we're the only pharmacy in Colorado that has since the pandemic offered vaccinations for COVID and flu down to six months old. Most pharmacies only offer vaccinations to children four or younger. I do feel like because of this, I have a unique relationship with many of the pediatric offices that know we offer this service, and that there are many offices that routinely send us their patients to receive these vaccines. We also offer test-to-treat services for a simple cash fee of $45, and I've never had a patient balk at this price. And I want to mention, too, that at one point, you know, pharmacists were not able to do vaccines and that was not too long ago, but I guess I would, I would argue that we do a pretty good job with vaccines now and I, uh, Ever since the pandemic, we've really taken that and owned that and really been proud of that. We don't even advertise our test-to-treat services, and yet we have a handful of people come in every week. We take their vitals and we have a consent form to determine if we should refer a patient to their provider. I really appreciated when Dr. Moore was talking earlier about referring. We have extensive training in when to refer. It's taken extremely serious by pharmacists to recognize a patient that we just can't help on our own. And I would hope that would bring some amount of peace to our physician partners. Dr. Keller brought up that like chicken soup is often the prescription needed. I totally agree with that and have often had a patient in front of me asking for a test. And it's clear to me that a test may not be necessary. So I guide them to some OTC options and ask them to check in with their PCP. We're not just testing anyone that asks. Also, we do have liability insurance, and I think I heard an amendment to notify physicians, which we are happy to do. And the first thing we do is ask if a patient has allergies. And to be fair, we are the ones that notify docs all the time when a prescription is written where a patient has allergies that we're aware of and that they weren't aware of. Thank you so much for your testimony. Please proceed. All right. Hi. Thank you, Madam Chair and members of the committee. Thank you for the opportunity to testify. My name is Jessica Angelson. I'm a clinical pharmacist, the practice advancement lead for the Colorado Pharmacists Society, and managing network facilitator for CPESN Colorado, which is a statewide network of community pharmacies building sustainable infrastructure for direct patient care services. I have a home between Leadville and Buena Vista. There's a pharmacy in Buena Vista that offers these test and treat services, which matters a lot out there. My son is 10. I do kind of know if he needs a more complicated service, but when he did have strep up there, we weren't able to take him there. And even if we had, our insurance didn't have to pay for that anyway. That gap is exactly what Colorado has been investing in closing. Pharmacists have been building toward a sustainable network of pharmacies serving public health needs. And through CPSN, we have the national infrastructure and the model to make it real. But if pharmacists can't get paid, they can't run a business. and then pharmacists won't join and we won't offer the services, which do go beyond just test and treat, but just all gaps in care. The investment only pays off when the payment framework holds. My work is building the infrastructure for community pharmacies to deliver and get paid for clinical services across Colorado. I can tell you directly that you can't build that service unless, if only part of the family that walks through the door can get treated, and you can't get paid by commercial insurance. Right now, commercial payers have no obligation to cover pharmacist services. They will not pay voluntarily. Without the payment reform in this bill, pharmacies can only reliably charge cash for those services with potential reimbursement from Medicaid. That is a fraction of the community, and you cannot build a clinical program on that. These are small businesses trying to fill a real gap, and the laws are making it harder than it needs to be. This is not a cost add. The alternative is for these patients to go to the emergency room. We've talked about that. but we're building something real here in Colorado that is filling that gap, and this bill will help us. So I urge you to support, I urge your support of House Bill 26-1336. Thank you. Thank you so much. Please proceed. Good afternoon, everybody. My name is Kayla Segovia, and I'm a fourth-year pharmacy student, but today I be speaking on behalf of Dr Ruth Olson who is a PharmD graduate from the University of Colorado Sky School of Pharmacy and a practicing pharmacist over at Capitol Heights which is a local independent pharmacy I am here today to advocate for expanding pharmacist's test-to-treat authority to include children younger than 12 years old. The current age restrictions create unnecessary barriers to care for families. Recently, I assisted two families that illustrated this disparity. In the first case, I was able to efficiently evaluate a mother with strep symptoms, perform a rapid trust, and prescribe antibiotics within minutes. However, when the second family arrived with their 8-year-old daughter, who also exhibited classic symptoms and had been exposed to siblings with confirmed strep, but current legislation prevented me from providing the same level of care. Because it was a Saturday and their primary provider wasn't available. However, I was able to perform a rapid strep test and work with another provider who was ultimately able to provide the prescription for the child. The age limitations caused undue stress to the parents and more time waiting for services I am fully equipped to provide. Updates to the current legislation would allow families to receive results and treatment in a single, less than 20-minute pharmacy visit, reducing the burden on urgent care centers and primary care offices. I appreciate your time and consideration of this important update to our state's health care guidelines. Thank you so much for your testimony. We'll move online to Dr. Schwander. Hello, my name is Dr. Kelsey Schwander, and thank you so much for allowing me to speak today. So I'm an assistant professor at the University of Colorado School of Pharmacy, but I'm really here today to talk about my practice site. And so I am a little bit different than the others. I am not working in a pharmacy, but I'm actually working in a clinic. And I'm really here to kind of address how we are not getting paid for our services, that part of the bill. So I work at the Marcus Institute for Brain Health, where I treat veterans, first responders, and active military who have mild to moderate traumatic brain injury. So my patients, I meet with them one-on-one. It's an intensive outpatient program. Most of our patients are from Colorado. However, we do have patients from all over the United States seeking care from our clinic. I meet with the patients. I go over a lot of their medications. I do a lot of deprescribing, so taking medications off. I treat headaches and migraines. I treat PTSD, anxiety, depression. I treat suicidal ideation, insomnia, substance abuse, nightmares, just to name a few. I'm an integral part of the team. I work on a team with neurologists, neuropsychologists, counselors, art therapy, speech therapists, and I know I'm missing many. But I round with the team. So after I meet with the patients, I meet with them for at least one to two hours during their three-week stay with us. I round with the team and I have very good recommendations, these medication recommendations. And together as a team, we put together a treatment plan that they take back home to their providers. And the biggest barrier for me right now is I am unable to bill for these services. And this bill would allow me to bill for these services. So right now I have to depend on my MD or my neurologist to bill for these services. So it just creates a lot more work for everyone, despite me doing all of the work. And again, this would increase access because if a neurologist or an MD is not in the clinic, I am not able to bill for these services, which then my clinic usually just eats that cost So again just a different perspective I urge you to support this bill Thank you so much for your testimony Dr Price You are on mute still There you go. We can hear you now. Thank you. Chair members of the committee, thank you for the opportunity to testify today. My name is Nikki Price. I'm a director of managed care pharmacy for Albertsons companies. I am a pharmacist as well, too. We operate community pharmacies across Colorado under the Albertsons and Safeway banner, serving patients in both urban, suburban, and rural communities across the state. Community pharmacies often serve as that first point of access to healthcare system for these families. Pharmacies are open evenings, weekends, we require no appointments, and are embedded in communities across the state. As mentioned earlier, pharmacists are trained for this role. Our pharmacists graduate from doctor pharmacy programs, accredited by the Accreditation Council for Pharmacy Education, pass a national licensure exam, and complete extensive clinical training. Pharmacy education includes a minimum of 1,740 hours of supervised clinical patient care, covering patient assessment, diagnostic reasoning, laboratory testing, medication administration, and therapeutic decision making. Pharmacists already care for pediatric patients every day, including calculating weight-based dosing, administering childhood vaccinations, and counseling parents and medication safety. And as one of the other panelists mentioned, Albertsons pharmacies also vaccinate down to six months of age, so we have great experience with our pediatric patients. Importantly, pharmacist-provided care does not replace pediatricians or the medical home model. It complements it. Pharmacies can provide that timely care for straightforward conditions while referring patients when clinical complexity requires a physician evaluation. When a child requires a physical examination or evaluation, beyond the pharmacist training, the pharmacist refers that patient to a physician or a pediatrician. This model has already been implemented successfully in other states. Idaho has operated under pharmacist standard of care prescribing framework for eight years. They were the first state in the nation to do so, including care for pediatric patients, with no patient complaints, no physician complaints, and no disciplinary actions related to pharmacist prescribing authority. There is a there is a process for these complaints, and that is to the Board of Pharmacy. And we have physicians who report on things today. I've been, you know, recipient of that information. And so there is a process already today. And as far as I know, and I know, there's been... Thank you so much for your testimony. We'll move on to Dr. Pil-Kemis. Good afternoon. Thank you, Madam Chair, members of committee, and thank you for the opportunity to testify today. My name is Serby Palkimis. I'm a practicing hospital pharmacist in Denver, Colorado, representing Colorado Pharmacist Society today. I'm also a mom of three young boys. I'm here today to support the bill, House Bill 26-1336. I want to start out with a situation that comes up regularly. A parent comes into the pharmacy with a child who has a sore throat and fever. It's the evening. The pediatrician's office is closed. Urgent care is full or far away. The parents aren't looking for convenience. They're looking for timely, safe guidance for their child. Today, without test and treat authority, all a pharmacist can do is send them elsewhere and hope care isn't delayed. Much of the opposition literature focuses on the risk of over-diagnosis or over-treatment, but that literature does not reflect how pharmacist care works under this bill. For example we hear that most sore throats in children are viral That true It exactly why pharmacist test and treat relies on clinical assessment plus testing not testing alone Pharmacists follow strict protocols, use exclusion criteria, and refer when symptoms don't fit. A rapid test confirms clinical judgment. It doesn't replace it. We also hear concerns about some asymptomatic strep carriers, but pharmacists are not screening asymptomatic children. This applies only to symptomatic patients actively seeking care, which is a very different clinical scenario than the studies cited in the paperwork that you received. Another concern raised is antibiotic overuse. As a pharmacist, antibiotic stewardship is core to my training. Test and treat protocols are standardized, limited, and referral-driven designed to reduce inappropriate antibiotic use does not increase it. Finally, this bill strengthens continuity of care by requiring communication back to a patient's primary care provider. This bill helps families access timely, evidence-based care while keeping patients connected to a broader healthcare system. Thank you for your consideration. Thank you for your testimony. With that, We'll turn it over to the committee. Any questions from the committee? Representative Johnson. Thank you, Madam Chair. This question is for Dr. Price. If parents asked for their information to just be shared back with their doctors, would you be able to do that if they filled out the HIPAA form? Dr. Price? Yes, at Albertsons Companies, we do that today. So for anybody that is a test to treat or any other service that we provide, no matter their age, we do get that consent. and then we fax that information over to their primary care provider so they have that on record as to what the patient's symptoms were, what was treated, and what medication was dispensed if there was one. Representative Johnson. Thank you. Follow-up question to that. I just want to make sure. So when that information is not being shared, it's because the parent decided not to fill out the HIPAA form. You're in compliance when you do that. They have to give that permission for it to be shared, correct? Dr. Price? Yeah, that is typically correct for us to share their records. Vice President of the Leader? This is for anyone. I'm curious, can pharmacists adjust dosage on blood pressure medicines? I would like to answer that. Dr. Angelson? Thank you for the question. Yes, there are ways that we can do it under protocol. We can do it under a CPA, which is our collaborative practice agreement. We can also, if it's not a newly diagnosed condition, which it is, there is room in the law for us to treat for any conditions that don't require a new diagnosis. Representative Luke. Thank you, Madam Chair. And probably for anyone here in the room or online, could one of you or a couple of you just expand on how you're qualified to handle these new services? We heard a little bit from previous testimony, but I just want to understand, like, you know, what training do you have that qualifies you to handle these services? I would like to answer. Anyone? Oh, sorry, we have two online. Dr. Schwander. Yes, I can answer that. So because I'm a professor as well, I do teach in the curriculum. So as pharmacists, we are fully trained on all of these services. The test to treat, sometimes you have to do a little more training for that, but we know how to treat these disease states. We know when to refer for these disease states. So it is very early on in their education that we are taught this. So this isn't actually anything new to us. It's just being able to perform the services in different settings. So, again, it's things that we're already doing in clinics. It's already things that we're doing and we're already taught. So we're heavily trained on all of this to treat this. Dr. Poe-Chemes. So I think this has been said already, but I can expand a little bit on this, that we go to pharmacy school for about roughly six years. Some of us go even longer. We receive a doctor of pharmacy where we have extensive curriculum going over all of this therapeutics and disease states and have algorithms and guidelines that we review and learn. And we do continuing education credits, 15 of them every year. And if you are licensed in other states, then you have to do even more extensive continuing education to keep up with these disease states and learn the most newest information. Some of the pharmacists, including myself, have even gone through residency training, which means an additional year or two specializing either in pediatrics, general medicine or oncology, cardiology, you name it, all of the subspecialties if we choose to do so. So we have extensive training in our education curriculum and in practice in hospital or retail setting to be able to give this care to our patients. Representative Vook. Thank you, Madam Chair. Quick follow-up, and again, for anyone. What does happen if you have a patient? What if you find something that's outside of your scope? Will they be referred? How do you handle that if that comes up? Who would like to answer that? Dr. Holmes? So if a patient comes in to me and we do have a consent form that we go through with them, And if it looks like, say, they have had multiple trips for the same type of issue, we're asking about that. If they are presenting with vitals that are just outside the norm of what we would expect, like we are referring for that. There's all sorts of things on our consent form that just go to what we are going to send somebody out for or keep them here. And I think we do a really good job following the evidence on that. Representative Stewart. Thank you, Madam Chair. My question is for, shoot, okay, sorry. I want to make, I'm trying to pronounce the name right. But for Dr. Palkimas, you, in your testimony, you had spoken about antibiotic stewardship. And I was wondering if you could elaborate on the training for that stewardship. Dr. Poe-Kemis. Thank you for that question. That's an excellent question. That is one of the core of our training. So when we are doing pharmacy school education, the final year of our pharmacy school is practice rotations where we are actually going to sites to learn and get our hands and feet wet to learn how to take care of patients. During that time, it's very much enforced upon us that we want to be good stewards of our medications, just like Dr. Schwandra mentioned, we not only prescribe, but we also help deprescribe. So we are an integral part in making sure we are not adding to more of overprescribing of medications So we have a keen eye looking at allergies making sure what other antibiotics have they received Is their symptom more viral compared to bacterial? And assess all of those things to make sure that we are prescribing antibiotics that's going to help. And it's not something that we need to just kind of think about viral infection. Antibiotic micro stewardship is very, very important to pharmacists because that is part of our training to make sure we don't have overuse of these medications. Because there is a resistance that can happen to antibiotics, and we don't want to contribute to that. This is why we're very careful in making sure we only use it when it's needed. Can I just ask a quick follow-up on, and I'm so sorry, I can't remember who said this, but that there's additional training on test and treat. Could you just expand, whoever mentioned that, expand on what that looks like? Or if you didn't have to have said it, but if you could just expand on what additional training you would need on test and treat. Dr. Price, I see you're off mute. Yeah, as a company, we actually provide that additional training on how to perform those tests as well as how to read those tests in addition to our protocols. So not only is it learned during your six years of education, but then as a company, we're also providing that training to any of our new higher pharmacists for flu, for strep and for COVID. And in fact, for many of the pharmacies that are out there using the strep and flu test, they're the same ones that the pediatrician offices and doctor's offices are utilizing today. Thank you. Okay. Any additional questions in the committee? Seeing none, thank you all so much for your participation today. We appreciate having you. We'll move on to our additional opponent panel, Dr. Amanda Jalinski, Dr. Alice Burgess, Dr. Chris Stile, Dr. Rusha Lev. Looks like most of those folks maybe are online. are there some other folks online just one okay let's also call up dr caitlin whelan mr kevin mcfattridge and dr robinson okay um why don't we start in person uh welcome back if you could introduce yourself to the organization you represent you have two minutes thank you so much uh chair and members of the committee. My name is Kevin McFatridge. On behalf of the Colorado Association of Health Plans, we appreciate the sponsor's work on House Bill 26-13-36 and the collaborative conversations to date. At a high level, we support efforts to expand access to care, particularly when it leverages pharmacists working at the top of their license and improves patient access in a safe and coordinated way. Our primary concern with the introduced version of the bill was language that could be interpreted as requiring carriers to contract with any willing pharmacy. From a plan perspective, that type of requirement can limit the ability to design networks that ensure quality, manage costs and coordinate care effectively We do appreciate the amendment that will be considered today which clarifies that the bill is not creating any willing provider requirement as you heard from the sponsor introductory comments This is an important fix that preserves appropriate network design flexibility while still advancing the bill's broader goals. With that clarification, we believe the bill strikes a more appropriate balance between expanding access and maintaining affordability and system integrity. We look forward to continuing to work with the sponsors and stakeholders as this bill moves forward and we appreciate the collaborative approach that's been taken. Thank you so much for your testimony. We'll move online to Dr. Whelan. Good afternoon, Chair and members of the City. My name is Dr. Caitlin Whelan and I am a pediatrician practicing in Aurora, Colorado, and I am here to oppose House Bill 26.1366 is written and urge you to remove the test and treat provision for children under 12. This bill is being framed as improving access, but for children, it really lowers the standard of care. Let me be clear, a test is not a diagnosis. I recently cared for a five-year-old who came in with a sore throat. In a test and treat model, he would have been tested, given antibiotics, and sent home. But instead, because he had a full pediatric evaluation, we diagnosed him with a peritonsillar abscess, a life-threatening deep neck infection that requires urgent surgery and IV antibiotics. A peritonsillar abscess cannot be tested and diagnosed or cannot be diagnosed by a rapid strep test. It is diagnosed by a full physical exam with the tonsillers identifying specific clinical signs and symptoms, asymmetric swelling that pushes the uvula to one size, trismus, difficulty opening the mouth, and decreased range of motion of the neck. Now, kids oftentimes have difficulty opening the mouth. It is my examination that can tell the difference between trismus and a kid who is uncooperative. That child did not need convenience. He needed a physician because if he was not treated correctly, his airway would have closed off, leading him not to be able to breathe. I've also recently seen an 11-year-old for sore throat strep positive. But because we practice comprehensive care, we did a routine screening and also discovered he was suicidal. This visit wasn't really about strep. It again was about saving a life. A pediatric visit is not just transactional. It is a relationship and it is an infrastructure through which Colorado's most vulnerable children access care. Pharmacists are critical members of the team, but this bill replaces clinical judgment with a protocol, and that is not safe for young children. We should not accept lower standard of care for children, our youngest and most vulnerable. Access should never mean good enough. Children in Colorado deserve comprehensive care in their medical home or developmental mental, behavioral, and mental health concerns are routinely identified with urgent exams. I urge you to consider removing the test and treat provision for children under 12. Thank you so much. We'll move on to Dr. Alice Burgess. Good afternoon, Madam Chair and members of the committee. My name is Alice Burgess, and I'm a pediatrician practicing in Denver. As a member of the Colorado AAP, I respectfully submit testimony in opposition to HB 1336. Being good antibiotic stewards is a core responsibility of our pediatric practice. Antibiotic overuse causes real documented harm to children. The stakes are not abstract. To preserve the effectiveness of the first-line therapies, kids must be carefully evaluated to avoid widespread antibiotic resistance, adverse drug effects, and microbiome disruption, all of which can occur when treating a viral illness with antibacterial medicines. They say a picture is worth a thousand words, and in this Okay Consider an eight patient who came into urgent care to see me for his painful sore throat He described the feeling of drinking fluids to be like swallowing razor blades Listening to his story I was initially concerned about strep throat but it turned out he also had a cough, runny nose, hoarse voice, and many sick classmates. My evaluation didn't stop there. I carefully assessed his throat, tonsils, lip nodes, ears, and lungs to ensure I wasn't missing a serious bacterial infection. Speaking with my colleagues about what test to order, they reminded me that group A strep testing must be interpreted in context as colonization is common. Studies estimating one in five school-aged children are asymptomatic carriers of this bacteria and thus will almost always test positive even when their symptoms are caused by a viral infection. I share this story to underline how medical decision-making in pediatrics requires nuance. Pediatricians have been trained to recognize red flags and calculate pre-test probabilities of bacterial versus viral infections. During my years of pediatric residency training, I evaluated hundreds of children with complaints just like this patient. Pediatric care is not simply following an algorithm. It requires integrating epidemiology, exam findings, risk factors, and growth and development. Convenience should not come at the expense of clinical rigor. For Colorado kids, the safest and most effective care is provided by clinicians trained specifically in pediatric medicine. For these reasons, I urge you to oppose HB 1336 as currently written. Thank you for your testimony. Dr. Stile. You are on mute. Sorry. Thank you. Thank you, Madam Chair and the committee for your time. My name is Dr. Christopher Stilla. I'm a professor of pediatrics at the University of Colorado Anschutz. I've been a practicing primary care pediatrician for over 30 years. I am urging you to oppose House Bill 261336 unless it is mended to exclude children under 12. We all agree that partnership is important. I would not have gotten anywhere in my career without partnership with pharmacists. They're some of the smartest members of my team. We also agree that access to care is really important, and we will continue to fight for that. But as written, I worry that this proposal raises serious concerns about pediatric safety, diagnostic accuracy, and the continuity of care for children. As others have said, a child or adolescent with a sore throat sometimes has a more complicated situation that people might think. I have seen children in my career with sore throat who actually have mononucleosis, potentially life-threatening infections, and or heart problems related to their condition. A simple test and treat strategy is inappropriate and unsafe for these kids, and their situation cannot be determined without a full history and examination. One example from my own experience that I use as a teaching tool was an adolescent with a bad sore throat who tested positive for strep, but whose main problem was actually mononucleosis that was becoming more severe. And simple treatment with antibiotics would have only delayed more important intensive management, not to mention he got a rash, which commonly occurs when people with mono are given amoxicillin for strep. And pharmacy-based testing can't replace a comprehensive evaluation, as other folks on this panel have said, and that can often serve as critical touch points for identifying other broader health concerns early. Pediatric visits frequently include developmental screenings, behavioral health assessments, and ongoing care coordination within a child's medical home. Removing children from this integrated care model risks misdiagnosis and delays in intervention. Colorado's children deserve the standard of care that only a comprehensive pediatric evaluation can provide. I'm happy to serve as a resource should you have any further questions. Thank you very much. Thank you for your testimony. We'll move on to Dr. Lev. Good afternoon, Madam Chair and members of the committee. My name is Rusha Lev. I'm also a pediatrician in Denver with over 15 years of outpatient practice experience, and I'm a board member of AAP Colorado. Thank you for allowing me to testify today on behalf of pediatricians and pediatric patients in Colorado. I'm here to oppose this bill as written. I understand the intent to improve access to care, and that is a worthy goal. However, this bill does not adequately account for the clinical complexity involved in testing and treating patients for infectious diseases, particularly children. The most common condition pharmacists would be testing for is strep throat. As you've heard, when children have a sore throat, only 20 to 40 percent of the time is it actually caused by the strep bacteria. Treating a strep carrier who's sick for another reason means an unnecessary course of 10 days of antibiotics. Accidentally treating mononucleosis with an antibiotic due to a false positive test causes an uncomfortable rash. Drug reactions to amoxicillin are painful, itchy, and distressing and usually require a follow-up visit to manage. Children who test positive for strep repeatedly may be better served by seeing an ear, nose, and throat specialist. Pediatricians are very mindful of inappropriate antibiotic use. The consequences are real. Adverse drug reactions, antibiotic resistance, disruption of gut flora, and in worst cases, C. difficile. Early antibiotic exposure in children has even been linked to many long-term health consequences, including asthma, eczema, food allergies, and obesity. This bill, as written, simplifies a complex clinical thought process to a swab and a prescription, but test and treat models are not in the best interest of the health and well-being of children. Without the components of a comprehensive assessment, potential life-threatening diagnoses, such as those mentioned before, retrofaryngeal or peritonsillar abscesses, epiglottitis, croup could be missed, leading to devastating complications. I urge the committee to consider these clinical realities. Please vote no on House Bill 1336. Thank you. Thank you for your testimony. We'll move on to Dr. Jachinski. Hi, good afternoon, members of the committee. My name is Dr. Amanda Jachinski. I am also a pediatrician and a proud member of the American Academy of Pediatrics. I come before you today representing both myself and the Colorado AAP chapter in a position to House Bill 1336 unless it is amended to remove the test and treat expansion for children under 12. This bill is dangerous to the health of children in Colorado in several ways, and I'm hoping today to spend a little bit of time expanding on what my colleagues have stated so far. So I work in Commerce City with a very underserved patient population. Many of my patients face multiple barriers in accessing care, including language barriers, as well as other social determinants of health. And I use every opportunity, including sick visits, to provide more than just a treatment for that acute concern. I perform comprehensive evaluations, screen for depression, screen for social determinants of health, and link my patients back up to more comprehensive care, including well-child checks. This bill aims to expand access to care for children, which is a worthy goal, but it doesn't do this in a way that protects the quality of care. Pharmacists are experts in their own area of study and rightfully so with the years of study that they perform But they are not experts in clinical care diagnostic assessments or pediatric health care. And in particular, I think you can appreciate that we as pediatricians get very concerned when the care of children is lumped in with the care of adults. We've spoken a lot about strep throat and the way it can be misdiagnosed, so I'm not going to repeat what my colleagues have said. But again, I would like to recommend that you hear the importance in gathering a comprehensive history, diagnostic past medical history, and evaluation of the patient, including a physical exam and performing an appropriate diagnosis. While we all agree that convenience matters to patients and families and that Colorado has a shortage of primary care providers, inappropriately expanding the test and treat model to children under the age of 12 does not address this concern. And instead, it jeopardizes the health of children in search of a quick fix for the larger primary care shortage. Thank you. Thank you so much for your testimony. Dr. Robinson. Thank you. Good morning, Chair Gilchrist and members of the committee. I'm Brigitte Robinson, trauma and general surgeon in Littleton and the president of the Colorado Medical Society. We represent more than 6,500 physicians across every specialty and every corner of the state. I want to begin by acknowledging what this bill does well. It expands pharmacist reimbursement and access to pharmacy services, which addresses a genuine need in Colorado communities. And we do appreciate the Colorado Pharmacists Society's ongoing partnership on shared advocacy priorities. Pharmacists are trusted, essential members of healthcare teams, and that relationship matters to us. That's precisely why the CMS today stands alongside the Colorado chapter of the American Academy of Pediatrics, Colorado Academy of Family Physicians, and the American College of Physicians of Colorado in raising focused concern about one section of this bill, the extension of independent prescriptive authority to patients younger than 12. Our concern is not about pharmacist qualifications in the abstract. It's about the clinical reality of caring for young children and the physicians who do the work every day who raises concerns most urgently. We believe this committee should weigh the perspective heavily. The bill provides a limiting condition, prescriptive authority, which would apply only when a new diagnosis is not required. That sounds protective, but in practice, determining whether a presenting child's illness requires a new diagnosis itself is a clinical judgment and one that's particularly consequential in patients who cannot fully describe their own symptoms. Those conditions can change quickly and who have developmental and physiologic differences that shape every prescribing decision. Colorado's children deserve a full benefit of that clinical judgment. CMS respectfully urges the committee to remove that provision in deference to the physicians who specialize in their care. Thank you for hearing me today. Thank you so much for your testimony. Any questions from the committee? Okay, seeing none, thank you so much for your participation. We will bring up our next proponent panel, Dr. Lucas Smith, Dr. Valerie Davis, Shannon Breckendorf Dr. Amber Sismic I going to bring up a few others Dr Ruth Olson Oh we already had I sorry Dr Fontania And Dr. Tara Vlasminski. I'm so sorry for mispronouncing your name. Okay. Let's go ahead and get started in person. If you could introduce yourself. the organization you represent, and you have two minutes. It's the tiny little button by the plug. Oh, hello. I'm Shannon Brinkendorf. I'm VP of Technical Solutions with a company that manages a technology solution for community pharmacy to deliver services. So I probably have a unique perspective on this issue, and I just want to thank the committee here for my time. Yeah, so just a little bit about kind of how our technology works. right, we enable pharmacies to deliver care. And so a patient registers for a service, they sign a consent, the pharmacist picks that up in our technology solution, and they manage the clinical encounter, right? And so they assess the patient. When they assess the patient, right, if anything is outside of range, right, we create an after-visit summary at that point and allow the pharmacist to communicate with the provider at that point. If they can continue on, they can test and treat that patient. And that's kind of what our technology does. If necessary, we will also actually query the health information exchange to pull additional data to support the protocol as defined. At the end of the encounter, right, so we've, let's say we've tested a patient, we've then treated them, we then have to bill the patient. Unfortunately, a lot of times this is cash pay, right, so this isn't offered for everyone. But at the end of that encounter, we're going to charge the patient. And in a lot of cases, what the patients prefer is really to bill their medical insurance. And in Colorado, we've seen some great payments and opportunities billing Medicaid. But for the commercial plans, it has been a challenge. So I know there's been a lot of discussion on the scope related to this bill in particular. my four is really related to the payment and that the commercial plans would sort of be required to stand up for with this bill passing. So that's why I'm here today in support of the bill and I really appreciate your time. Thank you so much for your testimony. Please proceed. Madam Chair and members of the committee, thank you for the opportunity to speak in support of HB 261336. My name is Dr. Ramel Fontanella, PharmD. I am a community pharmacy manager for King Super's Pharmacy for the union in Commerce City, and as well as an inpatient pharmacist for Intermountain Health. I'll be representing King Super's Pharmacy. I'm here to speak on behalf of families who need faster, safer, and more affordable access to routine care. This bill allows pharmacists to use the training they already have to treat minor test-guided conditions and to help kids and families out of crowded urgent care centers and emergency departments. A little bit about the community I do serve in Commerce City. I do have a UCH emergency room across the street and a PCP in the same parking complex as my King Supers. But the thing is, with my pharmacy, I'm open, more available, and also cheaper option versus emergency room across the street. Pharmacists are highly trained, credible health professionals. That training that we do go through emphasizes clinical assessment infectious disease management pharmacotherapy and patient counseling the exact skills needed to save test and treat services that we offer As one of the King Super trainers for pharmacists for NASPA certification for test or treat we've facilitated a 10-hour program with home-based studying, so six hours and four hours of life class demonstrations. Components focus on respiratory conditions, so influenza, COVID, and stroke throat. We use guided protocols. This includes sending a fax to the patient's PCP after the visit with a visit summary, including the medication that was prescribed. And we also do have liability insurance. We do have an extensive intake form that when the patient does show up, whether it's an appointment or a walk-in, they fill it out. So we know a lot of the conditions about the mental conditions, the allergies, and whatnot. So I'm fully entertained more questions about the training as pharmacists at King Soopers turns out for a test to treat. The bill removes the AIDS cutoff for currently prevents pharmacists from treating children under 12, even when a clear waiver which is FDA-approved tests, clearly identifies an illness such as strep, flu, and COVID. In the past, I've turned away many families who were seeking test-to-treat services for their children, causing undue financial and logistical burdens, forcing them to schedule PC appointments that delays in treatment or over-realization of emergency room visits. Quick, like I said, I don't have enough time, but overall, please support HB26 to expand safe and convenient and cost-saving scenarios for Colorado families. Thank you. Thank you so much for your testimony. We'll move online to Valerie Davis. Hi, good afternoon, committee. My name is Dr. Valerie Davis, and I'm a pharmacist in a health system setting. First, I'd like to address the fair reimbursement piece. As a pharmacist, I want to share the critical role my team of ambulatory care pharmacists play in the health care system. We work in a clinic alongside doctors, NPs, and PAs operating as an integral part of the healthcare provider team. We specialize in diabetes drug therapy management, monitoring and adjusting patient drug therapy per protocol to help patients achieve their glucose goals. We have our own internal data corroborated by published literature that demonstrates our patients achieve their therapeutic goals more frequently than those solely managed by physicians. Additionally, patient satisfaction data shows that patients highly value our services, recognizing the difference we make in their health outcomes. Despite providing care that is clinically equivalent and in some cases superior to that of other providers, our pharmacists face persistent difficulty receiving fair reimbursement for the essential care that we deliver. We ask that that disparity be resolved to support essential patient care. And then the other issue I would like to address is removing the age restrictions on pharmacist provider care. So as a parent, I can personally attest to the value of having various CLIA wave tests performed by a pharmacist, as this service is far more accessible than my child's pediatrician's office. However, the existing age restrictions created an inefficient and frustrating barrier to care. When my child's test result was positive, I contacted the pediatrician's office for guidance and therapy, and they suggested an appointment. The earliest appointment available was at the end of the day, which required me to take the entire day off from work. Adding to the inefficiency, once at the office, they insisted on repeating the test before determining therapy. The entire process was inefficient, unnecessarily costly, and frustrating. healthcare resources would have been better utilized by allowing the pharmacist to continue providing care for my child with any additional follow-up care needed with a pediatrician. So removing the age restriction would definitely help I want to say thank you and thank you for this opportunity. Thank you so much for your testimony. We'll move on to Dr. Sismik. Hi, good afternoon. Chair and members of the committee, thank you for the opportunity to testify today. I'm Amber Sismich. I am currently in a leadership role, but I'm an ambulatory clinical pharmacist by training. I've completed two years of residency. I'm board certified, and I've spent much of my career providing direct patient care in ambulatory clinics. So I know firsthand the abilities, the scope, and the expertise that pharmacists offer to patients. Also, pharmacists do carry professional liability insurance on top of what our organizations provide to us. Like many parents, I've experienced the frustration of trying to get timely care for my own children when they're sick, which often seems to be, you know, when their primary care office is closed or the doctor doesn't have any appointments available for a few days. Primary care providers or pediatricians may be preferred in managing these cases, but what do we do when the provider is not available? Do we go without care because we can't afford the costly emergency care visits or don't have access to an emergency department? It's already been stated this bill is not replacing that usual care within the patient-centered medical home. We are filling the gaps in care. Those in opposition say that it creates segmented care when patients aren't seen by their primary provider. But this would be no different than patients being seen at an urgent care or emergency department if their primary provider is not available. Depending on the electronic medical record system used, information might not be readily shared back with the primary care provider when they're seen within those settings either. What does happen with this bill is it improves their access. It reduces the strain on the urgent care and emergency department rooms for higher acuity needs, and it also helps better use our existing workforce, which is already in shortage. Therefore, I respectfully urge your support of House Bill 26-1336. Thank you for your time and consideration. Thank you so much for your testimony. Dr. Smith. All right. Thank you, members of the committee, for listening to my testimonies. and I urge you to support House Bill 261336. My name is Lucas Smith. I am pharmacist and owner of two pharmacies in Buena Vista and Salida. I'm also a member of the Arkansas Legislative Committee. So I'm testifying today for you to support this bill. In my community, access to care is limited. We have one walk-in health clinic in the whole county, which often gets severely overwhelmed, especially in the summer tourist season when people are here visiting and enjoying the river and hiking the mountains in our area. If you can't go to the walking clinic, it can take several days or weeks to get an appointment with a provider. Patients often face long wait times or delays that can worsen otherwise manageable conditions. In this gap, our test and treat services have become a critical access point in our communities. Our clinic here regularly, the walking clinic regularly refers to us to help relieve their workload. Unfortunately, with the current age restriction, there are quite a few people that we are not able to see at this time. We use a standardized pathway to assess each patient, identify red flags or high risk factors. Patients who fall outside the appropriate criteria are referred directly to higher level of care. And our workflow is further supported by using a technology platform. Enables us to seamless screen patients and ensure pharmacy staff consistently follow the established protocols In addition we follow up with every patient we see positive or negative on a test within 48 or 72 hours to ensure that they are improving or if their symptoms are worsening at that point because it's another contact point to assess the patient over the phone and maybe at that time refer them to a provider. There was a question about training. So all of our staff, all my pharmacists go through the National Alliance of State Pharmacy Association's point of care testing training, where we go over how to determine the accuracy and precision of a point of care test. You have to demonstrate that you can assess a patient and perform a proper swab for the test and many other aspects that help us, me and my other pharmacist, be prepared to see a patient and treat appropriately. I just ask that you would support this bill as it would allow for increased access to care and eliminate delays in treatment for people in our community. Thank you so much for your testimony. Questions from the committee? Okay. Seeing none. Thank you so much for your participation. We appreciate you being here. Okay, we'll move on to our final panel, Dr. Robert Vallock and Dr. Michael Hennenkamp. And then we have Mrs. Jennifer Holguin. And then anyone else who would like to testify in support of the bill today, or anyone online or in person that would like to testify? Okay. It's like we just have one person or others come in. Okay, let's start with Dr. Villec. If you could state your name and your organization, you have two minutes. Thank you, Madam Chair and members of the committee. Thank you for the opportunity to testify today. My name is Robert Ballack, and I'm a licensed pharmacist in Colorado since 1987, a professor at CU at the School of Pharmacy with some of my colleagues, and I'm the director of the Colorado Consortium for Prescription Drug Abuse Prevention, which was created in 2013 to coordinate our state's response to the opioid crisis. I'm here today to offer support from the consortium for House Bill 26, 13, 36, and wish to focus specifically on provisions one and two, which address payment for services within scope of practice. And I'm not going to talk about test and treat or the pharmacy technician related provisions, just provisions one and two. These provisions address a fundamental gap in our healthcare system in Colorado today. The gap between what pharmacists are authorized by law to do and what they're actually paid to do. Colorado has already taken very important steps to expand access to care, and I'd like to share how this impacts one particular area, which is treatment for patients with opioid use disorder or addiction. Today, due to laws passed in the past few years, pharmacists can now initiate and manage medication-assisted treatment for opioid use disorder using medications like Suboxone or buprenorphine under collaborative practice agreements with physicians using protocols developed by DORA using a very collaborative process with all of our health professional partners. This is really a true collaboration for the benefit of all Coloradans, particularly in rural and underserved areas. It's exactly the kind of policy innovation I think that we need and a step we can really be proud of. But without consistent reimbursement from insurers that authority does not translate into real access for patients In practice pharmacists can provide these services but are not reliably paid for them or they often excluded from provider networks solely because they're pharmacists. You know, the provider type is not covered under law. So the problem reduces to authorization without payment is not really access. The payment provisions in 1336 fixed that problem. They ensure that when pharmacists provide care within their legal scope of practice, those services are covered by insurers, including Medicaid, and pharmacists aren't excluded from networks simply based on provider type. Thank you so much for your testimony. Moving on. Thank you so much. Yes. Moving on to Dr. Hennenkamp. See you, doctor. Hello, Madam Chair, members of the committee. Thank you for the opportunity to testify. My name is Michael Hindenkamp. I am a pharmacist representing myself as an urban community pharmacy manager, as well as a member of the Colorado Pharmacist Society. And I'm here to support this bill because it allows pharmacists to be or to better meet the real world needs of Colorado families while also maintaining strong patient safety standards. I'd like to start with a brief example from my practice. A mother recently came into our pharmacy over a weekend with her two sons, one 15 years old and the other nine, seeking a flu and COVID test and treat consultation. Under the current law, I was only able to assess and treat the mom and older child. Despite identical symptoms and testing processes, I could not provide care for the younger child solely due to age. Faced with waiting for two test results and then trying to find another provider for her younger son, she ultimately left without receiving care for anyone. This wasn't a clinical issue. It was a systems issue. Patients choose my pharmacy because we offer convenient, affordable, high-quality care. Lowering the age restriction would allow us to care for families together, reduce unnecessary delays, and simplify an already complex health care system. Importantly, this patient access does not come at the expense of patient safety. Medication safety is the foundation of pharmacy practice. Pharmacists are medication experts with extensive training and appropriate therapy, dosing, and monitoring. We prescribe carefully, following evidence-based protocols, and only prescribing when it's clearly in the patient's best interest. Our protocol includes extensive referral criteria, and we also already provide communication to the patient's provider for all our current test and treat visits using a standardized form built into the visit. This bill also creates an important opportunity to better serve Medicaid patients through removing the statewide protocol limitation for payment. I frequently hear from patients who are struggling to find providers to accept Medicaid. Too often, their only remaining option for non-emergent issues is the emergency department. Allowing pharmacists to be paid for those minor self-limiting conditions would improve patient access while limiting ER visits. And then lastly, to address something that has been mentioned in previous panels, all of our pharmacists carry liability insurance, not only through our company, but through an additional liability purchase for ourselves. I thank you for your time and I urge your support for this bill. Thank you so much for your testimony. Do we have any questions for these witnesses? Okay. Seeing none, thank you so much for your participation today. We appreciate it. Okay. With that our witness testimony is closed Oh you got a question Well we can yeah yeah let come back Yeah we reopen the witness testimony to have oh wait did we lose him I lost him, okay. I'm sorry. That's not a ride. With that, we'll bring back up our sponsors. Okay, sponsors. Do you have amendments? Yes, ma'am.
AML Winter. I'd like to move Amendment L-001 to 1336.
Second.
I think Representative Johnson second.
We'll hold for just a second while Mr. Shadoon passes out the amendment.
I have it. Thank you.
Yes, we do. Thank you. Actually, while we're passing it out,
Amel Winter, would you like to describe the amendment? Yes, thank you, Madam Chair. We've been stakeholding this bill for quite some time, this predate session this year. So we've had a lot of conversation, and this amendment addresses numerous issues raised during additional stakeholder meetings. And I just want to say that there was a lot of things that we heard and we were definitely willing to give on. It refines pediatric guardrails, establishes a five plus age threshold for pharmacists to test and treat, responding to feedback from pediatric stakeholders, and it requires provider notification following testing or treatment, or a referral if no primary care provider is identified. And this is to help reinforce the medical home that we're always hearing about. It clarifies the scope of TPV and explicitly states that controlled substances are excluded from the technician product verification framework. It addresses insurance concerns, which we heard in testimony, which would bring one of the testifiers to support. And it clarifies that the bill does not create any willing provider requirement, reflecting input from the health insurance carriers. And finally, it provides implementation certainty. It sets rulemaking deadline for TPV at the request of DORA to ensure timely and clear program rollout. With that, I urge an aye vote.
Any questions from the committee on this amendment? Okay. Vice Chair Leader. We're not voting on that. Yeah. Vice Chair Leader. I have a subsequent amendment, L-002, to the L-001 amendment. Do you want to go ahead and move? I move L-002 to L-001. Second. Seconded by Representative Ferre. We'll pass those amendments out. While we're doing that, Vice Chair Leader, would you like to describe the amendment? Yes. So what L002 does is it removes from the bill the amendment independent prescriptive authority for pharmacists, for drugs, and devices for patients who are 5 to 11. So it's actually changing it. It's amending theirs. put it back to 12, to leave it at 12 years of age. Any questions from the committee?
AML Winter. Can I respond?
Absolutely.
I would urge a no vote. This guts our bill. We're trying to expand access. And for me, if your child's 12 years old and you have a nine-year-old sibling and they're both sick and you can't get into a doctor and then you go to the pharmacy and they can treat one of your kids and the other has to lay at home on the couch sick, this guts the bill. It gets away from the whole reason that we're doing this, and this is to be able to expand access for people that just can't get the care they need. So I'd please urge a no vote from the committee.
Representative Lindsay.
Thank you, Madam Chair. I too would urge a no vote on this amendment. I agree with my co-prime here that this really defies the intention of our bill. It guts it. And also we heard so much testimony today about 20 or so other states that are doing the same thing we're proposing here already with no age requirements and not seeing any problems that have been established since they began these processes. So we strongly urge a no vote on L2.
Thank you. Thank you, Representative Lizzie. Vice Chair leader.
Thank you, Madam Chair. And we did hear a lot of testimony. We heard a lot of testimony from the doctors. and it really pains me and scares me, especially being a grandma of a seven-month-old. I would not want a pharmacist. I struggle with 12. So I certainly would not want a pharmacist treating and diagnosing my grandson under the age of 12. It definitely, I mean, with the testimony here of how mono, My brother was five years old. He got mono from a drinking fountain. And, oh, my God, I can't imagine a pharmacist diagnosing that treatment. So with that, I urge a yes vote on L002.
Representative Johnson.
Thank you. And just wanting to remind colleagues, this is moving it down to five years. So a seven-month-old still cannot seek this option like other states are already doing. We heard testimony on pharmacists. When it is outside their scope, they will refer out. They will call. They will go get other people. In rural Colorado, though, this could be the option between them getting treatment or the issue getting worse. So we need to look at Colorado as a whole, all of our communities, and very much a lot of our pharmacists are the home care. They know the child best. IRG, no vote on the substitute amendment.
Vice Chair Leader.
Thank you, Madam Chair. It was metaphorical. He was seven months old now. I couldn't imagine him treating him at five. For clarification.
Representative Lindsay.
Thank you, Madam Chair. And I would just add, obviously, anybody here can still take their children to their pediatrician. This is not mandatory that people take any of their children to a pharmacy. This is an additional option to expand access to care. So, again, please vote no on L2.
Amy Winter.
Thank you. I won't speak any more of this. I just want to pose a question to the committee. if you had the choice to have your child treated at five years old by nobody or somebody as a parent, what choice would you make?
Additional questions from the committee. I just want to clarify just to make sure I understand and the committee understands. So your amendment, L001, brings the age limit to five, and then vice chair leader amendment amends that amendment to take it back up to 12 Vice chair leader That is correct Okay great Just wanted to make sure that was clarified for everyone in the committee So we seeing no additional questions are there any objections to
Object.
I'm sorry?
Object.
Representative Barone objects. Yes, I know. So this is, we're going to go real slow to make sure we get this correct. So L002 is what we are discussing right now. and Representative Barone objected to L002. I'll second. So we are now going to vote seconded by Representative Zabron. Oh, okay. We will now vote on L002. Mr. Sejun, please call the roll.
Representative Zabron. No. Bradfield. No. English. Yes. Frey. No. Hamrick. Pass. Johnson. No. McCormick. No. Rydon? No. Stewart? No. Winter? No. Wook? No. Representative Hamrick? Yes. Leader? Yes. Madam Chair? Yes.
The amendment fails on the count of four to nine. Okay. Now we will move on to back to L1, L001. So any additional questions on L001, Representative Johnson?
Thank you. I'd just like to clarify, I mean, in especially areas that we don't have resources, and we've seen so many EMS bills this year, it really is the option of can we give children in communities that have no option the option to have health care, or are we calling EMS, or are we going to the ER rooms for the areas that really are struggling to get resources? I'd urge a yes vote for children.
Are there any objections to L001?
Vice Chair Leader objects.
Mr. Shijun, could you please call the roll to vote for L001?
Representative Zabron. Yes. Redfield. Yes. English. Yes. Frey. Yes. Emmerich. Yes. Johnson. Yes. McCormick. Yes. Wrighton. Yes. Stewart. Yes. Winter. Yes. Wook. Yes. Leader. No. Madam Chair. Yes.
Passes 12 to 1. Okay. Additional amendments. Vice Chair Leader.
I'm sorry, did you have a...
Vice Chair Leader.
Thank you, Madam Chair. So I have L004. What this does is it adds health care providers' notification to the existing law when pharmacists exercise independent prescriptive authority for drugs and devices for patients 12 years and older but under the age of 18.
Any questions on this amendment?
Representative Johnson. Yeah, I'd like... I'm sorry, it's getting passed out right now. It's coming.
Yes, absolutely. I will continue with the dialogue, but Representative Johnson.
Yeah, and I just want clarity on if we are forcing this, where does the patient's rights, the parental rights come into play? We talked about HIPAA, that if the parents ask for this, it is already shared. So my question is, by forcing this, are we breaking any federal or health care laws that we are forcing this transfer without the HIPAA compliance?
Any additional comments as we're passing out?
Yeah, sorry, AML Winter. I didn't expect that question. I think it's a really good question, and I think that it's something that we should definitely talk about the stakeholders with, and we can continue this conversation on second. So with that, I'd urge a no vote.
Do you have an answer?
I don't know.
Do you want the drafter to come up Could the drafter join us please Welcome. I want to introduce yourself for the record.
Thank you, Madam Chair, members of the committee. Brita Darling with the Office of Legislative Legal Services. I will say that is a good question as well. I don't know what conditions they do test and treat for. I know that we have different ages of consent for medical care, so I don't know if parental notification would necessarily be appropriate. That's just the first thought off the top of my head. I don't know that it's an issue at all. I just wanted to say that I also hadn't considered that. I think it was just the idea that that's in the current bill. I'm sorry, that's in the bill that expands it from 5 to 12, and so I think Rep. Leader wanted to just make sure that the 12 to, you know, we do have under 18, so 12 to 17 would also be notified, but I actually don't know any broader ramifications. Vice Chair Leader.
Thank you, Madam Chair. Exactly, because theirs has notification in it, and all I'm trying to do is expand it up to the age of 18.
Can I just ask a quick question for the sponsor or vice chair leader? So in your current bill or the amendment that you are allowing for a provider notification, but just in a particular window, an age window, right, AML, Winter, Representative, Lindsay? Yes, ma'am.
The way I read the bill, we do. I just would like more time. I mean, after bringing the question up to her, I don't think this isn't something that we can't talk about. We've already had discussions. I just think this is something that to do on the fly, especially with the question that Rep. Johnson raised that has kind of thrown this into a quandary. I think this is something that we can work on on second readings and am committed to do. Vice Chair Lita. Thank you, Madam Chair. So this already exists in your bill. So then your bill is going to be – it has an issue then already within it, according to her question, because yours is notifying them to the age of 12. All I'm doing is extending that up to age 18. So your bill already has this in it. It's notifying it. So does it not have an issue with your entire bill?
Representative Lindsay.
I think that's a further discussion that can be had. I think that what we came prepared today and stake held or stake holded was the language in our amendment. And so we are open to some further discussion for that additional age range of 18 and under, because we had only worked it out with all our folks for the additional piece that is included in our amendment, which is five and above, five to 11.
Representative Burrott.
Thank you, Madam Chair. So I agree with the bill sponsors to bring an amendment that we don't understand or they don't understand or any of us will understand the unintended implications if we add it now. Now to – they said they're open to discussing this on seconds. If they bring back this amendment and go back to the stakeholders and make sure it doesn't have any unintended consequences, great. They can probably consider this on seconds. But to do it on the fly, I agree with you. there might be some unintended consequences that you might not foresee at the moment
and I do urge a no vote on this one as well Vice Chair Leader Thank you So if my amendment is an issue to their entire bill then their entire bill is an issue because they have made it the same thing It's not something new. I'm just lifting – I'm just making the age to 18 from they already have it in their bill to refer, to notify up to the – at the age of 12. So there's not – it's just changing the age is all I'm doing. if it's an issue in my amendment it's an issue in the entire bill
ok additional questions from the committee seeing none we need to move this representative Ryden I think I'm also interested in I think that this does make sense to include it for all young people all youth but happy to wait for you to go back to all the people that would be impacted by that since that's how current law is and I could see that working out on seconds. Additional questions? Okay, seeing none, we need to move the amendment. Vice Chair Leader.
I move L004 to House Bill 261336.
Second.
Seconded by Representative Frey.
Any objections? Representative Verón objects.
So we will vote on L004.
Mr. Chudune, please call the roll.
Representative Verón? No. Redfield? No. English? Yes. Frey? No. Hamrick? No. Johnson? No. McCormick? No. Ryden? No for now. Stewart? No. Winter? No for today. Wook? No. Leader? Yes. Madam Chair? Yes.
The amendment fails on a count of 3 to 10. Okay. Additional amendments from the committee. Okay. With that, amendment phase is closed. Sponsors, would you like to wrap up?
Representative Lindsky.
Thank you, Madam Chair.
Thank you, committee, and thank you to all the witnesses who came out today. I think it was a very vibrant discussion, and I think it's so important that we got to hear all the different perspectives. In my view, this bill is very basic in that it expands access to health care. It adds an additional health care option to people across Colorado, people in both underserved rural and urban communities. It helps busy families manage a household of kids of various ages and get them seen by a medical professional in a timely fashion, especially on evening and weekends. And even better, perhaps somewhere really close to home. And even better, somewhere that you can maybe also grab that gallon of milk while you're out. I, too, care about antibiotic resistance. I feel like as a kid back in the 80s, I think I ate them like candy. I was prescribed antibiotics all the time, and I worry about that for our larger society. And it's different nowadays, and doctors, pharmacists, and even parents are concerned about the overuse of antibiotics. In fact, my 18-year-old recently got her wisdom teeth out, and I was on her like a hawk. Finish every pill in that bottle. So I care about these things, but I also think that this bill does nothing to exacerbate that situation. I think that pharmacists care about this issue very deeply. I'm also confident in the reliability of Clearwave tests to identify things like Strep with high accuracy And allow pharmacists to then treat Like I said before you've heard that over 20 other states have no age Restrictions and they are not experiencing Negative impacts as a result We are not breaking ground here we are carefully Following the lead of nearly two dozen States who have already been doing the very thing That we're proposing and I look At this as teamwork to fill the gaps To add options which expands acts and keeps people healthy and able to get the care they need and deserved. When uninsured folks are paying out of pocket for medical care, and I just want to bring this up as uninsured people in a community like mine that's actually a large population and it's of everyday concern, the pharmacy is by far the most affordable option and could be a huge time saver as well. Not everyone has insurance. Not everyone can afford a trip to urgent care, let alone the ER. and not everyone can even take off time during the day, take off time from work to take the kid to a daytime doctor appointment. This bill gives people across Colorado more options and I am so proud to bring this bill forward with my co-prime, AML Winter, and respectfully ask for an aye vote. Thank you.
AML Winter.
Thank you, Madam Chair. Thank you, committee. I think it's been a good-spirited debate and I think we heard a lot of information and we always talk about the state and how different we are but it's kind of neat when we get to a point where you have an urban and a rural legislator that are both same facing the same type of issue when it comes to access to health care i think the thing that's important about this bill that we really got into the age area of this but i think the reimbursement for the pharmacists are huge this allows them to take pressure you heard the pharmacist from my district that literally says that he has doctor's offices calling them and asking them to take an overflow of patients because not only do we not have kid doctors, it's hard to find just primary care providers. And as we face, and you all know, they call it the silver tsunami in rural Colorado. We also have an aging population that needs to see doctors as well. And it's harder for them to get in and out of the house and set those appointment times. So I think that that's important. And I think that we're all common sense, pragmatic people. And one thing that we did hear out of the testimony from the doctors and the pharmacists was there was no smoke to any fire. It seemed like you had two sides talking about something. There was no data to back up that there was this massive emergency. I mean, you all know that if there was a huge problem with this, there would be tons of data to drive that, especially when we talk about kids. And nobody could really lay down any data that shows that this is ineffective or there are people suffering from it. And I think that to realize that we're all humans and anybody can misdiagnose somebody at one point or another, I think, was an important question that was asked by one of our colleagues as well. So I appreciate the conversation. I'm here to represent my people. And my people need help. And I'm willing to do anything I can to help those people. I've been on a physician's assistant bill. I worked with independent pharmacies last year to make sure that they can stay open because, you know, just recently in La Hanna, Colorado, Safeway shut down and they were the only provider of pharmaceuticals to veterans in the valley. I mean, we have an issue where we're at. we lost an OB ward in Lahuna, Colorado, and now most families have to drive an hour to an hour and a half to have a baby. And I just don't understand as a rural legislator how when I look at the options that you can either have a $2,000 emergency room bill, you can drive an hour and a half one way to a doctor, which is a three-hour trip, plus with all the other expenses that go along with that, because you all know how it is. When you go out of town, well, when you're from rural Colorado, when you go out of town, you're going to eat somewhere other than the three places that you have at home or your kid laying at home sick on the couch because you can't get into a doctor. And then to take two kids into the doctor and have a 12-year-old be able to be treated and a nine-year-old have to sit at home and be sick as well. And I understand where the doctors are coming from, but I will tell you in rural Colorado, we will self-treat because we don't have any other options. And I'd much rather have a pharmacist who has been through the training. We heard from the doctors that see you talk about the extensive training they have I would much rather see my people have that as their first line of defense they can follow up and see a doctor instead of self themselves because I think that would be a bigger travesty that any pharmacist could ever impose on any type of kid So I urge you all for a yes vote today. I appreciate you all. And thank you for listening. I know you listen to Rep. Lindsay, but I always bring it from the rural perspective. Thank you for listening to Rural Colorado. It's important. We're on survival mode right now. And a yes vote really helps out my district. So thank you very much, and I appreciate you all.
And, M.L. Wendell, you're on the committee today, so would you like to move the bill? It's going to the Committee of the Whole.
Yes, ma'am. I would like to move House Bill 1336 to the Committee of the Whole. Thank you, ma'am.
As amended to the Committee of the Whole with a very favorable recommendation. Second. I think Representative Wook seconds. Closing comments on the committee. Representative Stewart. Thank you, Madam Chair. Thank you, bill sponsors. First and foremost, I'd like to thank everybody that came out to testify. Pediatricians, pharmacists, I truly have that most respect for your profession. I was very interested in being a doctor until I realized how much math went into it. But truly, I thank you. It's not lost on me that when we were hearing from the pediatricians, I believe every single one of them was from the metro area. And as a rural representative, I noticed that. And I also heard testimony about convenience. And I do grant that in metro areas this could be a lot about convenience, but to AML Winter's point in rural Colorado, this is about access and survival. So I view it differently. I view this bill differently. I had this very interesting thing happen to me over the weekend where I was trying to take 24 hours for myself to be a person which seems rare in this job where my 12 year old daughter was complaining of a sore throat on Saturday night and she's had strep more than once and I said well in the morning on Sunday morning we'll see where this goes And then I ended up texting my friendly neighborhood pharmacist lobbyist. And I was like, where's the closest test and treat? Because I was like, man, I feel like nature really, like the universe, stepped in with 1336. And so to be able to have that option in rural Colorado, you know, it's a big deal. so I'm about expanding access and I understand that there are perhaps we disagree on the way we expand that access but in lieu of other options being brought forward I very much support what I believe is a common sense compromise to expanding access throughout Colorado so I am a happy yes today and I appreciate all the work that you've done on this thank you Representative Wright. Thank you, Madam Chair. I also wanted to be a doctor. Too much math? Yeah, I couldn't deal with physics, actually. Yeah, too much math. Thank you for being here today and for bringing this to us. I was, of course, a lean no moving into today's hearing because I'm very protective of, I think, kids and their unique needs that only, I think, a pediatrician really can manage. I also recognize though that I come from a suburban area which has a pretty decent amount of pediatricians So really what I was listening for today was is there harm that happening or could happen that would outweigh what else I was hearing, which was the access issue? Because again, I don't see that in my suburban district in the same way. So I was listening for, again, the other states that don't have the age limit and where it's been deemed that this has been dangerous. I didn't hear that. And, of course, our state, when we enacted this, allowed for 11, 12, 13-year-olds or 12, 13, 14-year-olds. So I was waiting to hear how that has caused harm or misdiagnosis, and I didn't hear that either. I also heard a really interesting thing about those who don't have primary care, specifically people who are traveling. That isn't something I thought of, that this is an easy solution for access, which applies to rural and suburban areas like mine, which I think pulled me more in this direction, as well as just what you were saying. Representative Winter from your district that three pediatricians and actually I think he said only two pediatricians that I can't imagine what that's like and I see that there's got to be other solutions and I think you were right in saying we talk about there being these healthcare deserts in much of our state but we don't come up with a lot of solutions and the only solution I heard from the other side was more investment in preventative care and I feel like we are trying to do that and if we still are not able to do that in a real way, then that's a problem. And so I appreciate that you've found a way to try to treat something. So I'm happy to support today, and I look forward to that conversation on adding that notification piece to primary care doctors for those who are under 18 or between 12 and 18. Representative Johnson. Thank you, Madam Chair, and thank you, Sponsor, so much. This will be amazing for House District 63 like it will be for 47, rural Colorado. And it's mentioned, the good co-sponsors mentioned, you know, this is an option. It's not a force. Why don't we give all the tools to our parents when they're trying to make sure our kids stay healthy? And yes, we do need more, you know, doctors in specialized areas for children, but that could be many years coming down the road. And this could work in tangent with that. We need to work together while we're finding solutions for healthcare, not fighting each other. And so I very much appreciate this and will be a strong yes. Representative Luke. Thank you, Madam Chair. Yeah, I'm definitely supportive. Thank you both for bringing this bill and Assistant Minority Leader Winter. Your focus on your district is impressive. I have no doubt that you listen to your people. I mean, it just shows. So I just want to take this moment to say that. Really, I just respect you for that. I think we all do it, but man, I just admire what you do. So great, Bill. I just think of the chance that someone is more likely to go see the pharmacist. Maybe before this they are like, maybe my son or daughter is okay. And then the pharmacist actually says, you know what, I think there's something more. You better go to the house. So I really believe that's going to happen. I actually think this is going to lead to positives in that regard. So I really appreciate it. Thank you. Representative Bradfield. Thank you, Madam Chair. I read this bill, and I truly was ready to vote for the 12-year-old cutoff, and then the testimony from so many parents and the pharmacist convinced me otherwise, and I thought about it in practical terms in my family so I appreciate your bringing the bill forward and I appreciate the fact that this is a real service to the people in rural Colorado, and thank you. I will be a yes today. Representative Burrell. Thank you, Madam Chair. And as an honorary OB given to me by the doctor that I saw after I delivered my second child in the front seat of a car on the side of the road, I can say thank you for this bill. I really do appreciate it. And it's going to help rural Colorado. So, yeah, I am an honorary OB. Thank you. Vice Chair Leader. Keep that in mind there. Thank you, Madam Chair. and I appreciate what you're doing for your people. You always do fight for your people. But after the testimony with the docs and the pediatricians it still scares me and without the amendments I have still grave concerns. I had a family member at five years old that got mono from a drinking fountain and I can't even begin to imagine that it would have been tested from a pharmacist. And you do need health care out in the rural area. HR1 is just going to make it even worse. So I don't know what the answer is. I'd like to see maybe a doctor from the city, suburbs, rove around and maybe be able to go to those pharmacists as a doctor, as a pediatrician and just kind of like rove around in the areas and they know when the doctor is going to be there. Do a mobile coming out there. But without that I'm a no today. I will say when I asked the question because I had no idea if pharmacists could adjust blood pressure medicine and that one was a very eye opener for me. I couldn't imagine a pharmacist adjusting blood pressure medicine. My brother was in the hospital and he was on the mend to leave and his blood pressure spiked. The nurse overdosed him on blood pressure medicine at the age of 52, and it killed him. They tried to revive him back seven times, and they couldn't do it. So I really could not imagine a pharmacist adjusting blood pressure medicine. But for today, I'll be a no. Thank you. Representative Hamrick. Thank you, Madam Chair, and thank you, AML Winter, and Representative Lindsay for really representing your districts and being champions for access. This was really tough. I understand and know pharmacists as well as pediatricians and family doctors are all mission-driven, and they want what's best for their patients. But I was a little concerned about the medical history sort of being lost in the process and fragmented care and symptoms masked by other symptoms. And I really appreciate all the work you've done with the pediatricians and family physicians to get this where it needs to go. I'm going to be a respectful no today. But I really look forward to you working more with the pediatricians and family physicians. Thank you sponsors for bringing the bill and for the work that you put into this. Thank you also for working with the stakeholders to amend and come to an agreement. level of agreement. I also really appreciate your passion for access, whether it's in urban Aurora or my district in Denver, which is very close to yours, or in rural Colorado. And, you know, Emma Winter, you and I spoke earlier about my passion to make sure that rural Colorado has access to health care and all Coloradans have equitable access to health care. And I'm deeply committed to that and appreciate that that is what you are trying to do with this bill. As I stated previously, I just always have very deep concerns about expanding scope. I understand that folks don't believe that this is an expansion of scope and we can agree to disagree, but that that comes with some safety risks that particularly around children just can't get past. And so really appreciate, again, you trying to work with the opposition. And I think also I would really love for the amendment that Vice Chair Leader presented and the idea to go forward on seconds. It sounds like you both are open to that discussion. and so really hope that that can go forward. I am a no today, but again, really appreciate the effort and the intention that we all want Coloradans to have access, particularly those that live in these healthcare deserts. So with that, Mr. Shadoon, can you please call the roll? Representative Sparone. Yes. Redfield. Yes. English. Yes, for today. Ray. Pass. Hamrick. We've got a flu no for today. Johnson. Yes. McCormick. Yes. Briden. Yes. Stewart. Yes. Winter. Yes. Wook. Yes. Representative Frey. Yes. Leader. No. Madam Chair. No. Your bill passes 10 to 3. You're on your way to the Committee of the Whole. Okay. We will now move on to House Bill 1328. It's the AML winter day in health and human services. I just get the judgment. It's three hours long, guys. And that's not even our long book. I'll get dinner and go. It's awful nice of you. Oh, yeah. He doesn't get paid enough. Although he doesn't get paid much. Okay. Sponsors, would you like to tell us about your bill? Who would like to go first? Representative Stewart. Thank you. Madam Chair in committee, Let us talk about House Bill 261328, which is non-emergency medical transport. So what is this? NEMT is a Medicaid-covered benefit that provides transportation to medically necessary appointments. It is essential for ensuring access to care, particularly for seniors, individuals with disabilities, and rural populations without reliable transportation. EFFECTIVE NEMT SERVICES HELP REDUCE MISSED APPOINTMENTS PREVENT AVOIDABLE EMERGENCY ROOM VISITS AND IMPROVE OVERALL HEALTH OUTCOMES WHILE HELPING CONTROL LONG HEALTH CARE COSTS COMMUTING TO AND FROM DOCTOR APPOINTMENTS IS A DEEPLY List appointments prevent avoidable emergency room visits and improve overall health outcomes while helping control long health care costs Commuting to and from doctor appointments is a deeply personal experience that can sometimes occur during the most vulnerable moments of a person's life, and not everyone is capable of driving themselves to each appointment, and there are real-life consequences to folks not getting their rides in time. Colorado patients need access to services that are safe, reliable, and ensure providers in this space are held accountable through transparent practices. So why are we bringing this bill? At a high level, this bill lays down a framework for implementing a statewide broker, ensuring that provider groups access our state, that access our state receive equitable support from the broker, hold providers accountable, and allows ethical businesses in this space an opportunity to grow while rooting out providers engaging inappropriately. NEMT services have continued to be at the forefront of conversations regarding waste, fraud, and abuse, and the need to address bad actors. This bill will ensure that NEMT providers will continue to be held accountable to appropriate policies and practices, have the opportunity to build businesses that best serve our communities, continue to serve both urban and rural areas, and most importantly, it will work to ensure patients feel safe and prioritized as users of this service. particularly as significant changes occur at the state level. What we are trying to accomplish is to mitigate access to care challenges in rural Colorado where distances are longer, provider networks are more limited, and transportation reliability is critical to maintaining care continuity. We're supporting a phased-in broker implementation to ensure stability in all regions as this transition takes place, including rural areas, ensuring network adequacy so rural members are not underserved or left without options, promote flexible scheduling policies that accommodate both routine and time-sensitive care needs, highlight the importance of maintaining continuity of care during transitions and program structure, and maintain patient choice in the new statewide broker model by maximizing patient preference whenever possible. And now I will turn it over to my co-prim. Amel Winter. Thank you, Madam Chair. Thank you, committee, again, and thank you, Rep. Stewart, for discussing the importance of this service and our goals for this legislation. I get to do the fun part, so I'm going to dig into some of the specifics for us and do a quick walkthrough of the bill. So Section 1 of the bill are definitions including non-emergency medical transport, or NEMT, transportation broker, and transportation provider. The transportation provider definition adds in the transportation network companies or TNCs, which we address in Amendment 0-4. Section 2 lays out the composition of the board, ensuring that representation includes urban and rural providers, large, medium, and small providers, transportation brokers, consumer and disability advocates. The goal of the Board is to act in an advisory board for the Department to provide recommendations and then work with the Department on a wide range of rules and regulations for NEMT services, including prohibiting trip caps, require reasonable accommodations to member requests, streamline a new process for filing complaints, establish a process for submitting claims, establishing procedures for appropriately handling recording from in-vehicle cameras, and develop billing procedures and an avenue to resolve billing issues it ensures that the policies around in vehicle cameras address member safety privacy compliance while not inhibiting providers from utilizing recordings for safety or driver accountability it also requires hick puff to provide notice when implementing bill changes Section 3 It outlines roles and responsibilities of the statewide broker Notably it lays out procedures for phased rollout. The broker must work with the state to set up systems for technical support, communication toolkits, and rollout in phased regions. Rollout to the next region must only occur when the first region is successfully up and running. The broker is responsible for determining Medicaid eligibility. Section 4 of the bill clarifies that the transportation broker is responsible for determining Medicaid eligibility. It also ensures that member privacy is protected throughout the eligibility process, including that a member's ID card is not displayed for video camera in the vehicles. In this section, we also clarify through Amendment AL-002 guidelines around the use of video recordings, when they can be requested for program integrity reviews or audits, and ensures that inability to provide video recordings due to retention policies cannot be used punitively against a provider. Section 5 deals with the audit portion of the bill, which we are amending through L-005. Mainly, our goal here is to ensure that the state is able to audit providers when deemed necessary to combat fraud, waste, and abuse, and ensure that providers are aiding and abiding by the rules. Currently, providers are able to be audited. However, they are conducting audits around claims. We want to ensure that they can audit beyond claims, such as provider policies and procedures, driver and vehicle appropriateness. Section 6, NEMT categorization to ensure federal match. Right now, NEMT services are categorized as an administrative service, and we are reclassifying as a medical service at the federal level in order to increase federal matching up to 90%. The current prediction, we believe, to be conservative, is $43 million in cash fund savings each year. $43 million in cash fund savings each year. $43 million in cash fund savings each year. Anybody else want me to say it? Section 7 through 10 and 8. So Section 7 through 10 cleans up NEMT services throughout statute and applies an effective date of July 1, 2026 and a safety clause. So basically, y'all, House Bill 26-13-28 modernizes Colorado's NEMT program to better serve Medicaid members, increase transparency for providers, patients, and others, support providers in effort to provide sustainable and ethical services and ensure the system operates with greater consistency, accountability, and reliability across both urban and rural communities. And with that, I urge a yes vote. Thanks, sponsors. Questions from the committee? Representative Johnson. Thank you, Madam Chair. Thank you, sponsors. Sponsor one, Representative Stewart is aware of all the questions I've asked on this program throughout committee this year. Sponsor two, you got to, you know, avoid all those questions, but this addresses exactly those questions, making sure rural gets what they need, urban gets what they need, and we're not doing that one-size-fits-all that we were concerned about last fall. So thank you so much for addressing that and recognizing, I know you both do, that what works in one area doesn't work in the other. So thank you so much. This is direly needed, and now Sponsor One doesn't have to listen to all my questions again. Is there, no, just a southern question. Okay. million a year Vice Chair Leader Thank you Madam Chair I just want to make sure this applies you said to TNCs not like assessor rides with RTD or anything just to TNCs or everybody Representative Stewart. I believe it is just the TNCs and the language we have in the amendment or one of the amendments. and just a special shout out to Mr. Shadoon for the passing out the excessive amount of amendments. So a round of applause, honestly. Okay, but we do have an amendment that addresses TNCs and essentially what it says is they have to follow the same protocol that any other provider would. Additional questions from the committee? Okay, seeing none, we will bring up our witnesses. Do you have a preference on who on order? opposition first or amend first and support? Great. So we'll bring up Ms. Rosemary Ferris, Alex Weschelbaum, Adele Flores-Brennan, Rosemary Ferris. Sorry, that I already called. We have a Ms. K. L. I don't know if that's a misspellinger okay and then thank you any folks online okay while they're pulling up the folks online if there's anyone else in the room that would like to join us that is in an amend or opposed position okay with that we'll turn it over to the individual here in person if you could introduce yourself the organization you represent and you have two minutes Great. Thank you so much, committee. My name is Alex Weixabom. I am the program manager of the NEM team at the Department of Healthcare Policy and Financing. The department has an amend position on this bill. The NEMT program has suffered many problems in recent years. The department is fixing these by implementing a statewide broker system this summer and fall. We have worked to find common ground with the sponsors of this bill, and we appreciate their engagement. There are provisions in this bill we support, and we remain committed to continuing that work. Amendments to Section 6 allow the Department to increase our federal match, and we commit to sending CMS a state plan amendment to enable that. However, as written, this bill does create serious financial risk to the taxpayer and jeopardizes our ability to manage the program effectively. Our most significant concern is market consolidation, especially in rural areas. The bill removes the tools the department needs to prevent large transportation companies from dominating entire regions of the state. Without these tools, our members lose choice in their provider, small transportation businesses get squeezed out, and the Department has limited recourse to address safety and performance concerns. We believe there is a path forward with the sponsors to address many of the issues this bill raises. but the provisions that enable unchecked market consolidation and provider shortcuts around the broker system are things the department cannot support in any form. I'm happy to take any questions. Thank you for your testimony. We'll move on to Kelsey Bell. If you could come off mute and introduce yourself and the organization you represent. You have two minutes. Hi, my name is Director of Southwest Center for Independence. We're located in Durango, Colorado in the southwest region of the state. Our nonprofit is a disability-led organization and we offer a lot of programs, but amongst all of our programs, we do a door-to-door accessible NEMT transportation. This program started because there was a big need in southwest Colorado for Medicaid transportation. We serve a lot of people who can't drive either due to disability or economic constraints to consistent transportation. We're one of only a couple NEMT providers that serve this region in Southwest Colorado. In 2020 and 2021, there was a statewide brokerage rolled out for NEMT providers. And it brought a lot of challenges to providers and to members on Medicaid statewide. There were many issues eventually that brokerage got rolled back to nine counties in Denver Metro Fort Collins area. So we're not, this isn't the first time we're looking at a brokerage statewide for NEMT services. A lot has happened since 2020 and 2021. There's been a lot of changes federally. There's been changes related to fraud and abuse of NEMT services as well. So it's understandable that we're moving back towards a statewide brokerage, but I urge everybody to really think about learning from the last time. And there were so many issues that really substantially impacted not just providers, but the folks that we serve who rely on this service to be able to access medical care. This bill aims to address a lot of the issues that we had last time, but hopefully have a brokerage rollout that's smoother and doesn't cause substantial gaps in service for people who rely on this and the providers doing service every day. So thank you for your time and consideration. Thank you so much for your testimony. We'll move on to Rosemary Ferris. If you could come off mute, introduce yourself and the organization you represent. You have two minutes. Hi, my name is Rosemary Ferris. Can you hear me? We can. Okay. So I thank you for letting me testify today. So I do use MedRide quite often. There was a time when MedRide was not running and I had to use other services and it was a mess. They would either forget to pick you up or they would make you wait for over an hour. The cars were dirty. They smelled like smoke. And somebody like me that has asthma and I have problems with my lungs, it's not good. MedRide always has clean cars, safe drivers, and they always pick you up on time, all the time. I've never had a problem with that. So I am a fan of MedRide. So that's really all I have to say. Thank you so much for your testimony. Questions from the committee? Okay, seeing none, thank you so much for your participation. We appreciate you being here today Okay we will move on to our support panels Let start with Gary Smith Craig Towler, Renee, excuse me, Renee Arocks, Patrick Davis, Tyler Chafee. And then Tyler Borzilleri. Man, I'm really messing up names today. I apologize. Okay, and then Amanda Schoenegger. So bad. I'm sorry, guys. I need more coffee. Okay. I think we've got everybody. We'll start with the folks in person whose names I messed up, and we'll start left to right. If you could introduce yourself, the organization you represent, and you have two minutes. Sorry to put you on the... We can start here. You want to start right? Okay. And tiny little button by the plug. There's a tiny little button by that plug. Amazing. Can you hear me? We can. Okay. Please proceed. Great. Good afternoon. Committee members, my name is Amanda Schoeniger. I serve as the compliance manager at MedRide. My role focuses on ensuring that operations meet regulatory requirements and that we maintain strong internal controls that support accountability, transparency, and program integrity. I bring experience from both provider side and from working with the state agency in my prior role. That perspective has shown me how important clear rules, consistent enforcement, and strong oversight are in making public programs work effectively. Non-emergency medical transportation is a critical component of the Medicaid program. Without reliable transportation, members cannot consistently access care, manage chronic conditions, or attend essential appointments. A well-defined compliance structure also helps ethical providers. Oh, sorry. This bill will strengthen the framework around documentation, audibility, transparency. Requiring more consistent standards from trip records, verification, and reporting will help ensure that services delivered are services billed and that providers are operating within clear expectations. strong oversight and clear enforcement mechanisms help create a level of playing field when all providers are held to the same standards it reduces opportunities for bad actors to exploit gaps in the system that stability benefits providers the state and most importantly the members who depend on those services medrides supports this bill and sponsor amendments as meaningful step forward toward a more accountable and sustainable NEMT program. Thank you for your time, and I'm happy to answer any questions. Thank you. Please proceed. Thank you. Good afternoon, members of the committee. My name is Tyler Borzileri. I'm a VP at MedRide, Colorado's leading provider of non-emergency medical transportation. For eight years, we have served the state's most vulnerable populations, seniors, individuals with disabilities, Medicaid members, connecting them to health care they deserve. Our goal always remains the patient's access to care and bridging the transportation gap throughout Colorado by delivering reliable and essential services NEMT is a lifeline When the patient misses a dialysis appointment a chemotherapy session because they have no ride the human and financial cost is enormous NEMT reduces hospitalizations saves the state health care costs, and ultimately improves health outcomes. We respect the intent to improve leadership, regulation, and oversight of this program. However, any new management model is simply an administrative tool. Its success depends on the strength of the underlying systems. As everyone in this industry is aware, there are existing challenges in the program, including documentation consistency, rate structure alignment, audit processes, billing guidance, and overall communication. A new model alone does not automatically resolve the issues, which is why thoughtful implementation, clear standards, and strong oversight remain essential. We believe this bill makes meaningful steps in that direction by establishing clear expectations, reinforcing integrity, accountability, and creating a framework to support both providers and assist the department. We stand firmly in support of this bill and amendments being advanced by our partners and sponsors. This legislative proactively combats fraud, waste, and abuse by integrating the right tools for long-term success. These provisions are not only administrative checkboxes, but they're guardrails that ensure program services. Patients are not just process, or patients not just processes. They form a foundation that works for patients, providers, and taxpayers alike. We urge this committee to move forward with confidence that the industry's best providers are ready and willing and able not only to meet these standards, but grow alongside the program built on accountability. Thank you so much for your testimony. Please proceed. Hi, my name is Tyler Chafian with the Colorado Hospital Association. CHA is supporting this legislation because it helps achieve an important objective securing a higher federal funding match for the non-emergency medical transportation program or NEMT. We believe this will help improve access to care and we are grateful to Representative Stewart and Winter for their leadership on this issue. We've long advocated that the Department of Healthcare Policy and Financing should categorize NEMT as a medical benefit rather than an administrative service. This classification change allows the state to fully leverage available federal matching funds. Those funds do go into the Chase Fund, not necessarily to the General Fund. Colorado is eligible for a 90-10 match of federal dollars for spending for Medicaid members in the expansion population. CHA strongly supports ensuring the state can fully draw down available federal funding, especially during a time when 70% of Colorado's hospitals are operating without a sustainable margin. The enhanced match for the expansion population will help relieve some of the pressures on the Chase Fund, particularly as the provider fee is ratcheted down over the next five years because of HR1. We strongly support protecting beneficiary access and appreciate the partnership of the sponsors, the partnership with the department, and we understand that the forthcoming language will advance this classification change while preserving access, including the limited areas of the state that need flexibility to offer this benefit as an administrative service. Thank you. Thank you so much for your testimony. We'll move on online. Craig Towler, please. Hello. Good afternoon, Madam Chair and members of the committee. My name is Craig Towler, and I'm the Director of Public Policy and Advocacy at the Center for People with Disabilities CPWD an independent living center serving Adams Boulder Broomfield Gilpin Weld and Jefferson counties and a member of the Association of Colorado Centers for Independent Living ACCIL which serves all 64 counties in Colorado And I here today in support of HB 26 on behalf of patients who rely on non medical transportation, NEMT. For many Coloradans, especially older adults, people with disabilities, and Medicaid patients, NEMT is not just a convenience. It's how we access essential care like dialysis, chemotherapy, behavioral health services, and routine appointments that keep us healthy and stable. While this system serves an important purpose, we continue to hear from our consumers and providers about challenges with reliability, coordination, and consistency. This bill is an important step towards addressing those gaps and making the system work better for people who depend on it every day. As the state moves towards a more structured system, including the use of brokers, it's critical that consumer protections are built in from the beginning. A broker model can improve coordination, but it also adds a layer between patients and transportation providers. That means we need to be very intentional about protecting the patient's experience. From an advocate perspective, that includes clear accountability when provide rates are late, missed or denied, responsive real-time support so patients are not left stranded, reliable scheduling for ongoing care, especially for high-frequency needs like dialysis or behavioral health, simple transparent appeals process when issues arise. These protections are essential to ensure that system improvements translate into real improvements for patients. It's also important to recognize that NEMT is not the same as ride-seer services like Uber. These trips often involve individuals with mobility challenges, complex medical needs, or cognitive limitations. Drivers are trained, vehicles are specialized, and trips are scheduled around medical necessity, not convenience. That distinction matters as we shape policy. This bill is an opportunity to strengthen the system in a way that supports both consumers and many providers who are working hard to deliver these services appropriately. With thoughtful implementation and a strong focus on patient protections, this bill can help ensure that NEMT consistently delivers what is intended to, safe, reliable access to care. Thank you for your consideration. Thank you so much for your testimony. We'll move on to Renee Arak. Oh, we can't hear you. You are off mute, though. Still can't hear you. Still can't. My name is Patrick Davis. Oh, I'm sorry, Mr. Davis. I'm so sorry. We're trying, we are having some technical difficulties with one of our other witnesses. Just give us one second. I'll give you a, I'll call on you as well. Okay. Actually, Mr. Arak, why don't we move on to another witness while you try to troubleshoot? Awesome. Okay, Mr. Davis, if you don't mind coming back off mute. Good afternoon. I want to thank you for allowing me to address this committee. It's very important, and I support this bill. I am transportation manager for Southwest Center for Independence. We're a small company. We serve rural areas of San Juan County and La Plata County. It's very important. I feel that we have this authority, an oversight authority, to be able to list our concerns. Not all providers are one size fits all. We're in such a rural area, and HICPUB has proven in the past that they don't listen to the concerns of the transportation providers. With this bill passing and with an oversight authority, we would be able to address our concerns, what's working and what's not working. The people that we serve are people with disabilities and aging. They have a lot of hurdles and we don't need to add more to it. Transportation providers need to have a voice and have someone to listen to. And I feel with this bill passing, everything will be a fair playing field, but we will also have that oversight authority committee to be able to talk about the concerns. I was in this in 2020 when we tried the first broker, and if we would have had someone that listened to the transportation providers, it might have worked. this time. I'm hoping that it works and I'm hoping that we will have someone that listens to us and we can voice our concerns as they come up. Thank you and thank you once again for letting me address this committee. Thank you so much for your testimony. Okay, let's try Mr. Arnock again. Arnock. He'll tell me how to pronounce your name when you come off. Good afternoon. Yay, we can hear you. Thank you for your patience and understanding. Thank you also members for the opportunity to present to you today. My name is Rene Arcos, representing MedRide. I'm here today to support this bill because as a non-emergency medical transportation driver, I take seriously the privilege and responsibility I have of ensuring the safe and reliable transportation of Medicaid members to their medical appointments. In my role, I meet people every day who are facing extremely challenging and trying circumstances. For many of them, non-emergency medical transportation isn't just a ride. It's literally the only way they can get access to the life-enhancing and, in many cases, the life-saving health care they need. Because of this, our clients need to know that their transportation will be on time and that they will be taken safely to their appointments. Clear expectations and consistent standards are needed in order for drivers to effectively accomplish these objectives. When processes are well-defined and clear, drivers can effectively provide safe, reliable service and a better overall experience for the clients. Strong oversight is essential in order to ensure the system is used appropriately and that resources are going to the people who truly need them. When there is accountability across the system, it supports both providers and members and helps maintain trust in the program. I support this bill because it helps create a safer, more reliable, consistent, and well-structured transportation system for all of the stakeholders. I thank you all for the opportunity to present here today and welcome any questions you may have. Okay, thank you so much for your testimony. And we'll move on to Gary Smith. Good afternoon, Madam Chair, members of the committee. I'm Gary Smith. I'm the Chief Mission Officer at Goodwill's Colorado. Goodwill's mission is to help people overcome barriers to independence, and non-emergent medical transportation provides that independence for so many Coloradans that lack transportation to get to their medical appointments. Last year, Goodwill served over 3,600 individuals through our NEMT program, Goodwill's, which we've been operating in El Paso County since 2018. Goodwill strongly advocates for the passage of this bill. The bill will lead to improved communication via a feedback loop among the boots-on-the-ground providers, the statewide broker, and the Department of Healthcare Policy and Financing. The bill protects HICPF's effort to root out fraud, and those efforts we certainly support here at Goodwill. It also provides for clear and standardized processes and a pathway for providers to voice support or concerns about those processes and any proposed changes The bottom line this bill recognizes and protects HICPF authority and ability to lead an efficient and compliant NEMT program while providing open communication among all stakeholders. Thank you very much for your time. Thank you so much for your testimony. Any questions from the committee? Representative Johnson. Thank you, Madam Chair. And I wish I'd been in the room for HICPF to ask this, so I'm going to direct this question to Tyler Chafee. Sorry. So a simple change from admin to medical coverage in the state can get millions in benefits for this program. Why hasn't HICPF done this before now? Mr. Chafee. That's a question best answered by HICPF. I do think in the testimony we've heard a lot of complexity about what can and can't happen without a broker. There are some requirements at the CMS level that the federal government is not going to do a reimbursement at that level for individually reimbursed rides. And so I think some of that, whether it's through a broker or direct-to-individual, may have played into that. But that is a question for HickPoff. Representative Batfield. Thank you, Madam Chair. There have been – this has been done. It falls apart. Then it's been done again. What are the biggest hurdles to get over to have a successful transport company? I would like to answer that. Anyone? Mr. Schoenegger? Ms. Schoenegger? You're referring to the broker being done? I think you're, there you go. Again, is that what you're referring to? Representative Bradfield. In general, thank you. The company in general, the service. Ms. Honig. Yeah, I would say clear guidelines and expectations would be something that would set a provider up for success. Does that answer your question? Representative Wook. Thank you, Madam Chair. I should turn my mic on. Thank you, Madam Chair. This is for Mr. Smith online there. I'm just wondering, what has it been like to be a provider of the program, given all the constant changes providers have experienced from HICPUF? Mr. Smith. Yes, well, I would say that's certainly been very challenging. We fully understand that HICPUF has had their own challenges since 2023 discovery of some fraud going on. But I would say the changes, particularly when they're last minute after an NEMT provider, a company has already established their budgets for the year, that makes it very challenging to that provider. Representative, did you have a follow-up? Okay, Representative Brown. Thank you, Madam Chair. And this is my question for anybody on the panel. You know, what is your experience working with HICPUF over the past few years providing NEMT services throughout the state? Who would like to answer that question? Mr. Borzileri. Yes. Thank you, Representative. I think just the ever-changing evolution of the program itself. I think HICPUF has a very difficult job in trying to manage federal guidelines with state guidelines. as Mr. Smith alluded to the ever-changing policy changes last minute communications has been very challenging for providers to set expectations with Medicaid members when we trying to pick them up So I think just the ever dynamics of it kind of makes it a challenge for everybody involved Representative Brown. Thank you, Madam Chair. And to follow up on that, what would be your recommendation to help you guys out in that situation? Mr. Barter, or is it Larry? Yeah, I just think clear guidelines. not putting communications or changes in rule, I'm sorry, not in rule, but into a memo. Communications into rule would help establish the rule for a longer period of time rather than communicating directly with the provider network via email or operational memos, that kind of stuff. Representative Johnson. Thank you, Madam Chair. Only because I know Tyler and I can't pronounce your last name or anyone with MedRide on this testimony, Can you explain how crucial it is that we are addressing both the rural needs because of distance and how urban areas are different and why we need that flexibility? Absolutely. Mr. Borzilleri. Yep. Thank you. Did you pronounce your name again, please? Borzilleri. Borzilleri. Thank you. I'm Chafee. So there you go. That's fine. That's fine. Yeah. Thank you, Representative Johnson. It is – it's very critical. MedRide has established itself as a leading provider across Colorado servicing rural counties first. We started in southern Colorado and expanded because we saw the need for people to get to their appointment not only same day for discharges and same day requests but also for pre-planning to their primary care physician. Sometimes in rural Colorado, you have to go a long distance to get to the care that you need to help whatever medical condition that you're going through. So really empathizing with patients and understanding what they're going through and working with the facility providers to understand the complexities around long-distance transports. And honestly, the transportation in general around rural Colorado, whether it's through the mountains or across the eastern plains, it takes a challenge and it takes some adapting to do that. Representative Johnson. Thank you, Madam Chair. And to the gentleman on Zoom who mentioned that this is not like Uber or Lyft. Sorry, sir, I can't remember your name. Can you point out again and just like emphasize why this is so vastly different on how you need to help people get into the door or have some medical training in case something should happen on a long two, three, four hour drive because rural is forever away from everything? Mr. Teller. Yes, thank you, Representative, for the question. Yes, so non-emergency medical transportation is vastly different than rideshare companies like Uber because of the training and the way the vehicles are specialized and just the way that whole process of loading into a vehicle is done. I am a bilateral amputee myself and a wheelchair user, and I've utilized an EMT before transferring from hospitals when I needed to do that. And just the type of knowledge you need about where to transfer, how to help with the transfer board, where to assist when helping a patient who is ambulatory move from a wheelchair to a seat getting buckled in, securing wheelchairs. And the list goes on and on. And in order to safely provide those services to a consumer and a patient in a thoughtful, human way that respects the individual space and understands that lived experience, you need to have that additional training. And that's not something that Uber drivers or cab drivers or anyone not trained is equipped to do that, and nor do I think they should be put into that position because it is outside the scope of their job. So that's why this type of service is so essential. Representative Brown. Thank you, Madam Chair. And to anybody on the panel again I just thought of this question What provisions of the bill is most important to any of you We have a few amendments coming We just want to make sure that what matters most to you and gives you more consistency and provides accountability to the department. So I would like to know that. I would like to answer that. I can answer that question. For me, from a compliance standpoint, I think accountability and clear regulations is what's most important to me. I don't know that everybody on the panel has the same feeling, but I would like to see a level playing field. All providers having to meet the same exact requirements, drivers credentialed, vehicles credentialed, and everybody on the road being safe. additional questions from the committee okay seeing none thank you so much for your testimony we appreciate you being here today is there anyone else in the room or online that would like to testify on this bill today okay seeing none the witness testimony is closed sponsors we hear you have some amendments just a few Okay, who would like to start? Representative Stewart. Thank you, Madam Chair. I move L002 to 1328. Second. Representative for a second. Representative Stewart, would you like to describe the amendment? This is, I believe, the multi-page amendment that you all got yesterday. There's quite a bit in there. There's the Transportation Advisory Committee piece, language that we worked with stakeholders on around trip caps, which I will certainly let my co-prime speak about. But there's also video cameras, record keeping, billing procedures, and second day or two day scheduling that came from Disability Law Colorado Children's and a dialysis provider. Any questions from the AML Winter, did you want to say something? Yeah. Take a little issue with the trip caps for the simple fact is the way it's set up. The government wants to insert itself into the market, and it just really surprises me because it seems like we get a back and forth sometimes as we talk downstairs about how we're going to work on a bill, and there's times that we don't want to get involved in the market, and it seems like now we want to get involved in the market. That surprises me because the way I understand you build a business is as your business grows, You add more cars. You add more drivers as you move along. And I think to artificially set a trip cap and then try to fiddle with the market is just kind of odd to me. I just wanted to put that on the record. Questions from the committee on this amendment? Okay. Any objections to this amendment? Seeing none, L002 passes. Okay. Moving on. Representative Stewart. Thank you, Madam Chair. I move L003 to 1328. Do I have a second? Amo? Oh, Representative, for eight seconds, would you like to describe the amendment? Representative Stewart. Yes, thank you. So this is around audits in response to feedback from HECPF on our current budget landscape This amendment changes the audit section to ensure HCPOF has statutory authority to do robust audits of providers ranging from reviewing claims to provider policies and procedures as well as vehicle and driver appropriateness. The amendment makes audits permissive at the discretion of the department based on available appropriation. Any questions? Any objections? Okay. Okay. L3 is passed. All right. Do we have any more amendments? Oh, Representative Kay Stewart. Thank you, Madam Chair. I move L004 to House Bill 1328. Second. First and second. Do you like to explain L003? Yes, I would. So this is TNCs in the NEMT space. The amendment ensures that TNCs that choose to provide NEMT services must follow the same rules and regulations that other NEMT providers are required to follow, and I will say we are having ongoing discussions. Okay. Is there any questions regarding this amendment? Any objections? All right. Seeing none, L-003 is adopted. Representative Sturr, would there be any more amendments? Oh, thank you, Madam Chair. Yes, there are. Thank you for asking. I move L005 to House Bill 1328. All right. It's been first and second. Would you like to explain the amendment? Yes. Thank you. So L005 is a recategorization of NEMT services from administrative to medical. This is what brings down the quadrillions of dollars from the federal government, or as my good co-prime stated, $43 million as a conservative estimate. A million. Thank you. Any questions regarding this amendment? Any objections? Seeing none, amendment is adopted. Representative Kay Stewart, do we have any more amendments? We do, Madam Chair. Thank you for asking. I know you're all on the edge of your seat. I move L006 to House Bill 1328. Second. It's been first and second. Would you like to explain L006? Yes, thank you. This is an exemption for ambulance services, so Representative Winter and myself very much want to make sure that we are keeping all avenues of medical transport open. And this was we consulted with MSAC, and here we are. Thank you. Any other questions? Okay. Any objections to L006? All right. Seeing none. L006 is adopted. Any other amendments? Shockingly, no. Committee, do we have any other amendments? No. All right. Seeing none, the amendment page is closed. Sponsors, would you like to wrap up? Representative Stewart. Yeah. Did you want me to move the bill first or just wrap up? Either. Whichever you would prefer. Okay. I move House Bill 26-13-28 as amended, as amended very well, to the Committee on Appropriations with a favorable recommendation. I second that. AML Winter seconds. Okay, closing comments, Representative Stewart. Thank you, I just wanted to take a moment and I guess perhaps center myself here and say that when I first came into the legislature last year I had multiple conversations with Kelsey Bell who testified today about the needs of NEMT in rural Colorado and how she was consistently running into issues with the department moving goalposts And so when I was approached by a group, a coalition of stakeholders, about putting up guardrails for this important service that truly is life-saving, we know this, we have the data, I was happy to pull that title and join with AML Winter because this is not a partisan issue. This is an issue for all of Colorado. And I would like to thank the committee for listening today. And with respect to health care policy and financing, I want to be very clear. we shared this bill over a month ago and we have worked in good faith to come to a consensus and get to a place where folks are comfortable our desire to work on this bill comes from the fact that in our communities our constituents rely on NEMT the program's success is essential to our communities as you're all aware our state has received an incredible amount of scrutiny on the administration of this program, and this is the legislature and the providers, along with the advocacy community, stepping forward and asking for guardrails and accountability on this program. The legislature has stepped up here to protect the program and provide the necessary accountability. We have worked directly with proponents like the hospital association to draw down the necessary federal dollars that the state has for years been leaving on the table. We've been leaving money on the table. And now we're facing a $1.5 billion budget crisis. So we remain committed to working with all stakeholders on this. And I ask for your yes vote. And I'll pass it over to my co-prime.
I am all winter. Thank you, Madam Chair. And thank you, committee. Thank you to my co-prime. This isn't a partisan issue. This is an access issue. And this is no different than we were talking about earlier. People in rural Colorado, they need to get to doctors. People in urban Colorado need to get to doctors. In our communities, it's more specialty doctors. You know, we're trying to fix a problem, and that's what's frustrating. Me and my co-prime have really dug in on this, and we've shared this, and we've worked in good faith. I'm wondering if HickPuff even looked at our amendments. You all know me. I take this job very serious, and I'm pretty upset that they would come in so hot considering the dumpster fire that they are right now. You have two legislators trying to make a difference in this state and to come and be criticized like that for a problem that should be dealt with already. You all know me, I can't stand for that and I have to put it on the record. This bill is important for the state of Colorado and to come down to the legislative branch and try to throw your weight around is wrong. And that's why what they're facing is what they're facing now. it's up to us to fix this problem. So I urge my colleagues, jump on board, let's fix this problem and show them how to lead forward. Thank you. I urge a yes vote. Closing comments from the committee.
Representative Brown. Thank you, Madam Chair. Sponsors, I'm going to be a strong yesterday. I realize and I see the hard work you're putting into this bill and trying to fix this problem. The back and forth with the department, the conversations with the hospitals, the providers, and the advocates. I know you will continue to work on this. The program has clearly been off track for a while. What the providers shared today should shock all of us about how difficult it has been to work with the department There are there are plenty of providers asking for accountability as we seen in some of the testimony and show that they are not committing fraud The department has allowed this program to get off the track, and I appreciate that you two are here to get it back on track. So I appreciate it again, and I will be here yesterday and tomorrow and the future days to come.
Representative Johnson. Thank you, Madam Chair. Thank you, sponsors, so much for your diligent work. Your bill, this bill, is direly needed as it tightens the broker accountability, using federal finances more efficiently to support access to care, pointing out that we need a fix more than ever. The administration and HICPF has led to the fraud ring that we have seen $25 million plus detected in four months of fraud from 2022 to 2024, leading to 64 providers suspended with federal indictments filed. We are losing federal dollars because of the inefficiency. We also saw an EMT upcoding error issues with HICPF's own inaccurate billing guidance causing tens of millions in unrecoverable overpayments, which is hurting Coloradans, hurting our patients. This fixes that. It brings everyone to the table, both for urban and for rural. This is direly needed now more than ever, and I highly appreciate what we're doing. It's going to save money, unlike in the past where we've been losing money because of inefficiencies. I will be a strong yes, and I'm excited to co-sponsor.
Okay, with that, Mr. Shadoon, could you please call the roll?
Representatives, but on. Yes. Redfield. Yes. English. Yes, for all the days. Frey. Yes. Emmerich. Yes. Johnson. Yes, for all the days. McCormick. Yes. Ryden. Yes. Stewart. Yes. Winter. Yes. Wook. Yes. Leader. Yes. Madam Chair. Yes.
13-0. Passes 13-0. You are on your way to the Committee on Appropriations. Oh no, he's on the committee. He's stuck here. Okay. Representative Iglesh, whenever you're ready, we'll hear 13-14. Thank you. Thank you. Representative Ingos. Thank you. First committee members thank you for listening today to House Bill 26 13 14 even though I talking to half of the committee But okay I will continue to go on And I just want to say everyone in here knows that
since I've been elected in 2022, I've been here in this building fighting for kids when it comes to education, when it comes to kinship, just different spaces for our young people. And I just want to say that I know that all of us in here care about the well-being of our children, and it looks different for all of us or we achieve those goals differently. But in this moment, the proposed legislation, the original intent of this bill is now lost for many different reasons. And I just want to elevate what Representative Winters said, although he's not here. But when people come into this space and flex and throw their weight around, but we are the ones that have been elected to do a job for the state of Colorado, sometimes the messaging can get lost. But I just want to say protecting kids will always be a priority for me, and this is one of the reasons why this bill came and not only that is one of my priorities but I believe it's a priority for many people in the state of Colorado that's actually experiencing different situations when it comes to being a parent or when it comes to being a grandparent and when we're talking about kinship and different things like that and when we get to the amendment phase I do have some amendments based on stakeholding and conversations with different people that will bring you clarity as to why this bill has, in my mind, been gutted. But I will say the work will continue and this is just a start and I will build on the work that has been started today. And House Bill 26-13-14 was introduced to address a structural issue within our child welfare system. And I will be the first to say the family court system in Colorado needs to be overhauled. There are a lot of loopholes. There are a lot of laws in place where parents can use them against each other. And it's just not a fair system holistically, especially the family court system, because since I've been an elected official and prior to that being on the school board, I've had so many different conversations with families that have been affected by this family court system. The evidence is well established that children experience greater stability, improved permanency outcomes, and stronger developmental continuity when they remain connected to family networks. And this family stability and kinship bill is why it's so important for us to prioritize our kids. And I think sometimes we can lose time. side of that in conversations on prioritizing our children because I don't feel like oftentimes we think about the trauma of our decisions that really impact our kids, especially when it comes to issues like this. Now, the original bill reflected the body of research. It attempted to move beyond aspirational language and instead embed those principles into enforceable statutory frameworks. This is not where the bail ultimately landed. The narrowing of this legislation did not occur because the underlying research shifted or because the needs of children and families diminished because there will always be a need need, and this has been an issue for years. It occurred within the context of a legislative process that is shaped by what I believe representative, no, minority leader, assistant minority leader Winters identified. So for me, it occurred within the context of a legislative process that is shaped in part by organized interests that are not accountable to voters, but have the capacity to influence outcomes through sustained presence, financial resource, and institutional access. And that's where I believe the message is lost. Yes, I said that out loud on the microphone. That dynamic is not unique to one part of your ideology. It's structural. But its consequences are not abstract. They are born by children who are separated from family systems and by families who encounter a system that does not consistently prioritize them. The question before us is not whether this bill is as expansive as originally intended. it is whether the remaining provisions remove, no, sorry, whether the remaining provisions move the system toward a more coherent, equitable, and family-centered framework. And all of us view family different. All of us define family different. but at the end of the day, our priority should be prioritizing the safety and overall well-being of our children. The core analysis to the kinship placement as a uniform legal standard, which will identify some of the amendments as I continue to move forward in this. The bill maintains a statutory directive that prioritizes placement with relatives or kin when a child is removed from the home, absent of finding that such placement is not in the best interest of the child. This is significant because in the absence of clear statutory prioritization, placement decisions are shaped by administrative convenience, resource constraints, and individual discretion. Embedding this priority in statute reduces variability in application and shifts kinship care from a preferred option to a governing standard statutory alignments as a mechanism for equity The bill aligns language governing kinship placement with existing provisions in Colorado law to establish a uniform interpretive standard across jurisdictions. Inconsistent statutory language does not simply create ambiguity, it produces differential outcomes. When courts and county departments operate under varying interpretations, similarly situated families experience different results based on geography and institutional practice rather than consistent legal principles. Within the child welfare system, that inconsistency directly affects whether children are placed with relatives or with non-kin and therefore whether they retain access to their existing familial relationships. Documented diligence as enforceable accountability. The bill requires county departments to document their diligent efforts to identify and contact grandparents and other kin following the removal of a child from the home. This requirement shifts the standard from implied effort to demonstrationable action. Historically, the absence of documentation has allowed systems to assert that efforts were made without establishing the scope. timing, or adequacy of those efforts. That gap has tangible consequences, including delayed kinship placements and the unnecessary disruption of family connections. By requiring documentation, the bill creates a record that can be evaluated, challenged, and improved. It transforms family identification from a procedural step into an accountable function of the system. The bill also updates definitions. So it's modernizing statutory treatment of grandparents related to grandparents and great-grandparents in the context of family time and repeals outdated statutory language that previously governed how their role was evaluated in child welfare proceedings. This is a necessary correction that the definition of grandparents and great-grandparents is updated in statutory language. Statutory language does not operate in isolation. It encodes assumptions about family structure, caregiver legitimacy, and the evidentiary weight assigned to extended family relationships. Outdated provisions can perpetuate frameworks that undervalue the role of grandparents or apply evaluative standards that are no longer aligned with current practice or research. Modernizing this language ensures that legal decision-making reflects contemporary understanding of family systems and does not rely on legacy assumptions that distort outcomes It is accurate to say that this bill is more limited than initially introduced However, the remaining provisions are not incidental. They establish clear statutory expectations, reduce interpretive inconsistencies, and introduce enforceable accountability in how family connections are identified and prioritized. In a system where small statutory differences can produce significant real-world consequences, these changes are material. And I will pause there. Thank you.
Questions from the committee? Representative Wright. Thank you, Madam Chair. Representative English, I don't know a ton about this, so I've been trying to learn more and more about it. I certainly hear about parenting plans, and that certainly from the clients that I serve and that I work with in my other life. I have a question about Amendment 3, L-003, and I'm curious why, I think I understand where you were going with the strikeout and putting that later, but why take out the youth's preference? I mean, that to me says that that should be a priority. Representative Vick. Thank you. I believe Ms. Melanie Jordan will be here to answer that question. I was working with her on some of these amendments, so she could better explain that from a legal standpoint because I'm not an attorney. Additional questions from the committee. AML Winter. Thank you, Madam Chair. Thank you, sponsor. My question is, we always talk about unfunded mandates in places like mine. How, like for small counties, will we expect them to absorb the different things that they're going to have to do to implement this? Representative English. Well, I haven't had the opportunity to explain the amendments, but a good amount of this bill has basically changed completely. So a lot of these expectations won't even have to be met. Additional questions from the committee. I just have one, Representative English, and maybe this isn't relevant anymore with the amendments, but we passed two big kinship bills in the last couple years, House Bill 23-1024, relative and kin placement of a child, and then also Senate Bill two years ago, 008. both of those focused heavily on the prioritization of placement with kin. So I was just wondering if you could talk about how this bill is different from that and what this is doing that's in addition to what those bills accomplished. Representative English. Okay. I'm not too – I'm familiar with them, but not familiar enough to distinguish the differences. However in working with Melanie and she in this particular space and the recommended amendments came from her I think she could better explain why the statutory updates are needed for consistency which is what already in current law from the bills that have been passed into the difference that this particular policy will establish Okay, thank you. I can direct those questions to her. Additional questions? Okay. Seeing none, we'll move on to the witness testimony. I think we can bring everyone up if you're okay with that. Do you have reference? Okay. We'll bring Cecily Reine, Emma Pitner, Renee Bernhard, who's testifying in place of Jody Britton, if Jody Britton's online. Nicole Drake. Kayla Zillman. Melanie Jordan, who's in person. and then Marilyn Dawson and then we have Gina Hughes from the Department of Human Services for questions only. I don't know if she's online or in person. Okay, with that, why don't we start with Ms. Jordan if you want to introduce yourself, the organization you represent and you have two minutes. Thank you, Madam Chair and members of the Health and Human Services Committee for the opportunity to testify in support of 1314 as it will be amended today. My name is Melanie Jordan,
and I'm representing the Office of Respondent Parents Council today. I greatly appreciate Rep. English's commitment to ensuring relational permanency for children expressed through this bill. The ORPC supports children being able to maintain important familial relationships in their lives, even when parents are deceased or children have become separated from their parents. I also appreciate her responsiveness to the concerns of ORPC and the other child welfare stakeholders. With the amendments being offered today, the ORPC is in support. In 2021, the ORPC worked with Senator Buckner and Representative Ransom to create post-adoption contact agreements, commonly known as open adoption or PACAs, because we recognize that what is important to many parents is relational permanency. While the amendments today mean this bill will not address post-adoption contact agreements, the ORPC agrees with Representative English that more can be done to improve these agreements and hopes to work with her and other stakeholders to improve this process in the future. Regarding the other amendments, in 2023, Representative English passed House Bill 23-1026 to improve and clarify standards for grandparent family time. At the same time, our agency worked on House Bill 1024 to prioritize relative and family placements. While most of the grandparent visitation statutes were relocated, CRS 19117.7 was not repealed or relocated, and it is creating confusion. L-003 will resolve that confusion. This repeal has been on the wish list for a statute group convened by CDHS for several years as an important cleanup and clarification measure. L002 addresses a finding from the Colorado Supreme Court from the KMS case in June 2025 by clarifying that grandparent remains a grandparent even after the death of their child. This is a common sense, and I'm sure any of you who are grandparents would believe, yet it is important clarification following the 4-3 decision from the Supreme Court in June 2025. The remaining amendments are responsive to stakeholder feedback and ensure uniformity and language throughout the Children's Code. We appreciate Rep. English's attention to these areas and are happy to answer any questions about our position.
Thank you for your testimony. We'll move on line. Ms. Emma Pinter.
Hi, Rope Girl Crest, our Madam Chair. Thank you so much. Hello, everyone, members of the committee. My name is Emma Pinter. I currently serve as an Adams County Commissioner. I'm here testifying on behalf of Adams County in opposition to to House Bill 26-13-14, the Family Stability and Kinship Care. While we do understand that some amendments were, significant amendments were circulated last night, I have not had a time to process those with our human services team in full, and so I will be speaking to the bill as introduced, and we will be following up with any written comments as needed. And while we agree that the intent to facilitate positive familial relationships, this bill presents significant challenges. We are concerned that the requirement for counties to refer parents to family time services if they are current on child support payments could put domestic violence victims at significant risk. In some cases, victims have removed themselves from a dangerous situation without ever having made a report or otherwise engaged in court systems. If the counties do not have this information, automatically referring people to family time services could put victims back in harm's way, reopening a door for increased contact with their abuser for themselves and their children. This bill would require kinship care providers to become certified caregivers within 90 days, which would likely delay placement and potentially decrease the number of kinship caregivers in the system. The required enforcement of grandparent contact agreements in the cases of adoption is legally gray and would be challenging to implement. All parents, including adoptive parents, have legal rights to dictate the contact their children have with other parties. Requiring parents to maintain contacts with grandparents could create tense familial relations to the detriment of children involved. Current statute allows courts to enter in post-adoption agreements, which we are comfortable with, but requiring these is a step too far. Adams County remains committed to supporting children and families through difficult transitions and circumstances. Unfortunately, this bill, 13-14, would only complicate those efforts, and we respectfully urge a no vote today. Thank you, Madam Chair and the members of the committee for your time.
Thank you so much for your testimony. We'll move on to Renee Bernhard, who's, I think, testifying on behalf of Jodi Britton.
that's correct thank you madam chair hello everyone i'm renee bernhardt the founder and executive director of be the source we are a non-profit supporting foster kinship and birth families experiencing child welfare i am reading the following testimony on behalf of our director of family services jody britain good afternoon madam chair and members of the committee my name is jody britain director of family services at be the source a non-profit supporting families impacted by child welfare, I am also an adoptive parent through foster kinship care. Even without a post-adoption agreement, or PACA, my son maintains relationships with some biological relatives because I determine what is in his best interest, an essential part of parenting. I respectfully ask you to vote no on House Bill 26, 13-14. While Colorado has made important progress in prioritizing kinship care, this bill raises serious concerns. Family dynamics, in dependency and neglect cases are often complex, maternal, paternal, and the standards for safety during a case can differ significantly from what parents, caregivers, and counties believe is best for a child. We work with many fostering kinship families who must manage difficult and sometimes harmful family interactions, even reporting concerns to the hotline during active cases. Too often, their concerns are dismissed despite being well-founded. Requiring ongoing relationships through PACAs risks keeping courts involved in decisions that should belong to parents and undermines their ability to act in their child's best interest. While we support addressing grandparent rights outside of dependency cases this bill goes too far It adds complexity without nuanced solutions to an already challenging time and may discourage adoption an unintended consequence that ultimately harms children in need of
permanency. Thank you for your time. Thank you for your testimony. We'll move on to Nicole Drake.
Hello, good afternoon, Madam Chair, committee members. Thank you for allowing me to speak with you regarding this bill and express the department's opposition to the bill in alignment with our County partners. My name is Nicole Drake. I'm the Permanency Manager at the Division of Child Welfare under the Department of Human Services. My time working with Colorado children, youth, and their families has really ingrained the importance of children and youth maintaining safe, healthy connections with their families, including their parents and grandparents. Colorado has also worked hard to embrace a kin-first culture, implementing meaningful practices, significantly increasing our certification and payment of kinship foster parents. We recognize that children, youth, and their families should also only enter the child welfare system when there are concerns regarding the safety of a child or youth. However, we are concerned with these additional requirements, such as the modified safety and suitability assessment and the pilot to pursue expedited kinship approvals, as well as the additional training requirements and increased workloads this will create when Colorado already has a well-supported kinship navigator program that we have implemented to fidelity. In addition, the requirement for grandparent contact and post-adoption agreements represents a substantial shift in the requirements for these agreements. It limits the rights of adoptive parents and has the potential to create barriers to permanency for children and youth. Despite the amendments we understand are in progress, the department believes more conversation is necessary before we can adjust our position. We are always happy to come to the table for further discussions, and I'm available for any questions you may have.
Thank you for your time today. Thank you so much for your testimony. And then we also have Gina Hughes on for questions only, but if you could introduce yourself and the organization you represent.
Absolutely. Good afternoon, Madam Chair, members of the committee. My name is Gina Hughes, and I'm the policy unit manager for the Division of Child Support Services, which is under CDHS. Thank you so much. Okay, questions from the committee. Representative Bryden.
Thank you Madam Chair Hi Ms. Jordan
Question for you around the amendment L003 I think I'm not quite clear on the intention of that but I'm really curious why the preference, the youth's preference to make their choice in placement was eliminated I'm sorry
Ms. Jordan
Thank you Madam Chair and thank you Rep. Brayden for the question I think that was completely inadvertent. So what happened is that when we saw this language, we were trying to make sure that what occurs in other sections of the Children's Code is paralleled. 1024 put the same exact language, sorry, House Bill 23, 1024 put the exact same language in multiple sections of the statute. And so in trying to make this language parallel what's in other sections, I think that youth preference was just inadvertently taken out. So I would have no objection to that being clarified and that language is staying in and I apologize that I didn't catch that before.
Sorry, can I ask just a follow up? So Ms. Jordan, just to clarify, so the amendment as currently written, you would be okay with adjusting given that it takes out that youth preference? Yes, Madam Chair.
Absolutely. I think that youth's preference regarding placement should just be added at the end of youth mental physical and emotional needs including the child youth or youth preference regarding placement I think the reason that it happened is that in other sections of the Children Code it a separate provision rather than being attached And I think Rep. English was absolutely correct to call out that the way we have it worded here could be improved to ensure that that presumption appears in all of the places. So that's something that can definitely be fixed, I think.
Other questions from the committee? Rep. Hamrick. Thanks, Madam Chair.
I believe there's a question about sort of prior legislation and how this adds to the situation. Can you elaborate on that?
Ms. George.
Thank you, Madam Chair. Thank you, Rep. Hamrick, for the question. Yes. So in 2023, there was a lot going on regarding relative and kin prioritization and placement and also grandparent visitation in two separate bills. And there's a provision related to grandparent visitation, which is 19.1, 117.7. It just doesn't work with those changes that were made in 2023. It creates different requirements for grandparent visitation that were addressed by other statutes in that year. And so we've had it on our list for a long time that that needs to be repealed as a prior inconsistency and appreciate that Rep. English was willing to make that amendment and make that happen. That was absolutely something that was supported in our CHS statute group that includes county attorneys, OCR, our office, that current law addresses that and that the existence of the statute is just complicating things to leave it in there. and Ms. Jordan where so which amendment addresses the issue you just mentioned that is at the top of L003 line two and so sorry just to make sure that I understand so this is the can you walk us through what exactly that what the the group the statute group was recommending and how it fixes what the problem it's fixing? Ms. Jordan. Yes. So it is repealing that statute in its entirety, 19.1, 117.7, and that's resolving the inconsistency that we created in 2023 when we passed three different bills dealing with grandparent visitation and relative and kin prioritization. It's just a leftover statute that we no longer use and creates confusion. Got it. Okay, thank you. Additional, Representative McCormick. Thank you, Madam Chair. Yes, Ms. Jordan, I'm just curious to know, I'm hearing from you that L003 and L2 are kind of conforming, cleaning up. The other parts of this bill, could you tell us how you're and why you're in support of the other parts of this bill that, as amended, help build on any of the kinship laws that we've passed in the past? Because I'm a little confused. Ms. Jordan. Thank you, Representative McCormick, for the question. I think definitely as introduced, we had some concerns about this conflicting with prior legislation, specifically 24-08 and 23-10-24. I think the amendments resolve all of those concerns, and I think the amendments address the concerns that the other witnesses testified to, takes out all of the provisions related to post-adoption contact agreements, so those are no longer in this bill. It does make some changes in language, but I think those actually make the statute more understandable and consistent with those prior legislations. So, for example, one of the changes is adding the requirement to document diligent efforts to locate Ken. We do have that in another section of statute, but it's hard to find, and I don think it hurts to have it also repeated in this section Representative McCormick Thank you And on that note that they already required to document efforts to fine kin So having it repeated again in this bill does not add additional work for the counties. Is there anything new happening in the bill that I'm not clear on? Not just the cleanup and not just the clarification and all that. Can you speak to that? Ms. Jordan. Yes, the repeal of 19.1, 117.7 is important and is new. And then the amendment, which is L-002, addresses that Supreme Court case from June of 2025 that has not had a chance to be addressed in statute yet. That clarifies that a grandparent is still a grandparent even if their child has died. So there was a Supreme Court case from June of 2025 that found that if the grandparent's child was deceased, that they were no longer considered a grandparent. It was a split decision, 4-3. And so this is an amendment that was not put forward by our agency, but that we absolutely support to clarify that case and make that clear. And a follow-up question on that. So if in L002 clarifies that a grandparent is a grandparent, even if their child is deceased, that doesn't impact any contract, visitation contract going forward. Ms. Durd. Thank you for the question. Yes, that is correct, that it does not impact any post-adoption contact agreements. That statute, which is in Title 19, remains the same, and this definition is getting put into Title 14. so it would not impact those agreements at all. Thank you. I have a couple questions for Ms. Pinter and Ms. Drake or the folks from CDHS. If you could talk a little bit about your position given the amendments and have you been able to determine or shift as a result of the three amendments that are being proposed today? Ms. Pinter. Thank you so much, Chair. I will go quickly just because I can say we have not had a time to fully review with our legislative team at Human Services, and so I can't comment, but we can follow up in writing because I know you will be considering this bill moving forward. Thank you. Ms. Drake or Ms. Hughes? Yes, thank you, Representative. We also would need to do a more thorough review before where we could provide anything back regarding our position on the amendments and could also provide something in writing. Thank you. And then I guess also for Ms. Bernhard, have you have I know you're speaking on behalf of someone else, but if there it has be the source adjusted their position, given the amendments, Ms. Bernhard. Thank you, Madam Chair. We tried today to get through all of the amendments introduced last night, but just haven't had enough time. I'd be happy to spend some time looking and also submitting our comments in writing. Thank you. Okay, additional questions. Yes, Representative McCormick. Thank you, Madam Chair. So just to reiterate, could this potentially be a statutory cleanup bill? And it's just coming in this form. Ms. Jordan. Ms. Jordan. Thank you, Madam Chair. Thank you, Representative McCormick. I don't think so because I think it is a substantive rather than a technical change. It is a section of law that exists that requires certain requirements in terms of evaluating grandparents. for contact. We have moved away from the approach that's in that section. So I do think there's a substantive component to taking it out. I think that there was broad agreement in 2023 to make these changes and make these amendments. And just with all of those changes happening, it did not get moved or repealed in the way that it should have. So I think it goes beyond what the statutory revision committee is able to do. Additional questions from the committee. Okay. Thank you all so much for your participation. Appreciate you being here today. Okay. Is there anyone else online or in person that would like to testify on this bill? Okay. Seeing none, the witness phase is closed. Representative English, would you like to move your First Amendment? Yes, I move Amendment L-001 to House Bill 1314. Second. Seconded by Vice Chair Leader. Would you like to describe the amendment? Yes. Amendment L-001 removes provisions of the bill creating a foster care prevention services pilot program and requiring evaluation of the pilot program. So it takes that completely out. it removes the provisions of the bill concerning parenting time disputes. So it completely removes that. It also removes provisions of the bill allowing non-custodial parents to be referred for supervised or facilitated family times when they are compliant with child support obligations. And lastly, it removes provisions of the bill requiring the court to make specific findings when entering a final adoption decree or when denying, reducing, restricting, or terminating a grandparent's post-adoption contract agreement. So it completely removes the post-adoption contract agreement. And that's everything that L-001 does. Okay. The Health and Human Services Committee will go on to a brief recess. Thank you. Thank you Thank you I withdraw that motion to move L-001 to House Bill 1314. With that, the amendment will be withdrawn. Oh, okay. And at the request of the sponsor, we are going to lay over this bill for action only to a later date. Okay, thank you. Thank you, Representative English. Okay, we are going to get started on our next bill, but we'll just take a two-minute recess because we need to get the sponsors here. The Health and Human Services Committee will go into a two-minute recess. Okay. Thank you. Thank you. Thank you Thank you Thank you. Thank you. Thank you. Thank you. . Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. Thank you Thank you. Thank you. . Okay, the Health and Human Services Committee will come back to order. Welcome, sponsors. Please tell us about your bill. Who would like to go first? Representative Joseph. Thank you, Madam Chair. Thank you members of the committee. It's a pleasure to be here with you today to present 1267 House Bill 261267. I want to start by thanking Representative Mabry for all his work on this particular bill. I started working on this bill since I believe last May or June, and Rep Mabry and I have been working together on this particular policy, so I want to thank him for his zealous advocacy for this particular piece of policy. I want to start with my talking points, and then I'd like to add more into some of the substance of this bill. This bill is deeply personal for me. Like so many Coloradans, I've experienced what it's like to get sick and then be left dealing with the financial aftermath. And what I've learned is that medical debt doesn't just stay on paper. It follows you. It creates stress, uncertainty, and in many cases, real fear about what could happen next. This legislation is also informed by the incredible work of Colorado Center on law and policy who have spent years documenting how medical debt collection practices impact families across our state. I want to also note there are so many wonderful organizations that have been supporting us on this particular policy, but I remember last May they were the first group of people that I reached out to when I told them this is an important particular policy for my district and the people of my district, and also when I recounted to them as well some of the personal experiences that I had with medical debt. What we are trying to do here is simple. Set clear, humane boundaries. First, this bill put a stop to the extreme collection practices, things like seizing someone's home, garnishing wages, or going after retirement savings. When someone is recovering from a medical crisis, those kinds of actions don't just collect. these type of actions don't just collect debt, they destabilize lives. Second, it ensures that people can maintain a basic level of financial security. Even in collection, you should still be able to afford rent, groceries, and the essentials that keep your life moving forward. Third, it brings transparency into the process. Patients deserve clear notice, clear information, and real opportunity to understand their options before any serious collection action is taken. And importantly, this bill creates accountability. If these rules are violated, there are real consequences because protection only matters if they can be enforced. At the end of the day, this is about balance. It does not eliminate medical debt. It does not prevent collection, but it ensures that processes are fair, reasonable, and grounded in dignity. Because getting sick should not mean losing everything you've worked for. I wanted to mention as well the coalition that we been working with has done a lot of great work on this particular piece of policy If you read the original bill and today we do have a strike below L1 and L2 but the point is when you look at both bills, you can look at the first bill, it's a very, very substantial piece of legislation. And I do believe the first bill would have made groundbreaking differences in the lives of our community members. But because of the work that we've done with stakeholders, we know that we come to this capital with legislations that means a lot to our communities and we bring 100% of everything that we think would help our communities. However, after conversations with our stakeholders, we've pared down this bill tremendously. And because of that, I would like to ask you for a yes vote on this particular bill. I wanted to talk about, again, the strike below that you have completely rewrites the bill. It pairs it down a lot. It replaced this bill with a much more detailed and stronger framework regulating medical debt collection in Colorado with the focus of protecting patients from aggressive and harmful collection practices. It broadens health care providers. It defines medical debt. medical creditors as well and there is stronger protection against aggressive collection practices such as those what we call impermissible extraordinary collection practices around threatening to take someone's home or personal properties and also going after non-patients and also one of the most important part of the bill as well for me and I would imagine also for Rep Mabry is the protection around deportation or using immigration status as leverage, and also seeking to arrest or jail over medical debt, garnishing of rages, and taking money from retirement accounts, disability savings account, and education savings. We also have, we're amending the strike below as well. I'll stop right there. Again, as I've mentioned, the bell is very, very pared down. I want to stop to give Representative Mabry the opportunity to contribute to this conversation. But again, I hope that you will vote yes on this particular piece of policy because it is about all community members. It's about real humans and human lives. And I think most of us probably here have had medical debt as well. I don't think I'm the only person who's experienced medical debt. I'll stop right there and ask for a yes vote. And thank you to Representative Mabry again and to all those who are here to testify on House Bill 26-1267. Thank you. Representative Mabry. Thank you, Madam Chair. Thank you to my co-prime advocates and members of the committee. I first want to acknowledge that I know this is the part of session where we're here late at night. People are probably ready to go home. I know there are 90 witnesses here. I have some things I want to say about this bill because I think this is one of the most important pieces of legislation that is being brought this session. And lots of people have worked incredibly hard on this policy. And so I ask that committee members bear with me as I go through some points here at Introduction that will be highlighted by the lived experiences of the people who are coming to testify. Colorado is one of the wealthiest states in the wealthiest country in the history of the earth and it is a moral failure that we have neighbors who face bankruptcy eviction and homelessness because they got sick Our legal system is being weaponized against working-class people who are buried in debt. Court orders for wage garnishment take away the autonomy of our neighbors to decide how to spend their own money to manage their finances and live their lives. That is wrong. This bill is not about whether people owe money for medical debt. That is a separate conversation, and it is one that is long overdue in this building and one that I would love to have. Today's conversation is much more specific. It is about what legal tools we are choosing to hand to medical debt collectors to extract money from our neighbors who are buried in debt because they got sick. These are two different questions. You can believe that a debt is still owed and believe that wage garnishment, home liens, and asset forfeiture are wrong, especially when these tools are not essential to how our health care system is funded. We have to think about how our legal system treats different people differently. The legal system treats corporate debt as a financial instrument to be managed. It treats working class debt that is a result of people being sick as a personal moral failing to be punished. That status quo is a moral failure of the state of Colorado. It's about protecting a widow who was forced to sell her late husband's wedding ring just to avoid losing her home over a hospital bill. A mom of four who was forced to take out payday loans for diapers after her wages were garnished. A family that was facing medical debt approaching a quarter million dollars, roughly 175,000 of which resulted from a mistake made by the health system. The provider failed to file the insurance claims correctly. The insurance didn't pay, and by the time the legal machinery caught up with this family, they were facing bankruptcy and losing their home. Their home, because the hospital's billing department failed to do its job, and a family paid the price. While families are being dragged into court and having their wages garnished over medical bills, some of the hospital systems in Colorado are reporting billions, billions in profits. It's $1.3 billion in the Denver metro area alone. This is not a broken system. It is a system designed to work this way. Working class people are constantly on the losing end of encounters with big hospitals, debt collectors, and insurance companies. But if billing is done incorrectly, if claims go unfiled, if codes get entered wrong, and if coverage gets misapplied, the consequences for families are devastating. They can lose their homes, their jobs, their lives. And what about the mechanisms for accountability when that happens? When the hospitals do a mess up that ruins somebody's lives, how hard do you think it is for a patient to hold that hospital accountable? And what happens to that hospital if a mistake is made? They're not falling into financial ruin. I will tell you that. But these mistakes that hospitals can make in the building space can ruin people's lives. Medical debt can make it three times more likely that somebody becomes homeless two times more likely they become food insecure People in medical debt are three times more likely to be in poor health, and they're two times more likely to forego medical care completely. I know we're going to hear stories about that today. And courts in Colorado approve approximately 14,000 wage garnishment orders for medical debt every single year. Now I want to be clear about something. This is really important. And this, in every conversation in this building, especially right now, when our constituents are begging for us to make our state more affordable, it is not our job in this building to get lobbyists who oppose a piece of legislation to a place of neutrality. That cannot be the standard that we grade ourselves against. It is our job to work with stakeholders in good faith to hear their concerns and then pass legislation that makes our constituents' lives better. We have done that without one. It is a substantially narrow version of the bill. We sat with opposition. We made real meaningful concessions. We removed comprehensive payment plans that were required. We removed a detailed 30-day pre-collection notice requirement. We removed a requirement that there would be a cap on how payment plans would work. By the way, our legislation was model legislation put out there by the National Consumer Law Center, and we have taken it down to just be about three main things. We gave a great deal, but we are trying to ban wage garnishment for medical debt, ban liens on patients' primary residence, and ban seizure of assets below $5,000. $5,000. The average rent is about $2,000. This is a month worth of expenses. Colorado lags behind taxes and consumer protections for people buried in medical debt. Think about that. Texas, not California, not Massachusetts, not New York, to my Republican friends, which is normally the states I'm citing, but Texas. Texas protects families from medical debt collectors better than we do. And it never expanded Medicaid. Texas made a deliberate policy choice to leave over a million of its working class residents without health insurance. And the Texas Constitution protects its residents for almost all wage garnishment, period. Texas does not permit wage garnishment for consumer debts. If a Texas hospital sues a patient, wins in court, has judgment in hand, and they still cannot reach a patient's paycheck, and somehow the Texas health care system has not collapsed, providers have not fled the state, patients still receive care. And I'll also note, Texas has far, far more rural communities than we do. In a state that refused Medicaid expansion, I am sure there are rural medical providers in Garland, Texas. They made a deliberate choice to leave working class people without coverage. They can still provide care in their rural communities without wage garnishment. Why can't we? I also have asked repeatedly for evidence that wage garnishment is essential to the business model for any provider in the state of Colorado. I have received nothing to suggest this to be the case. In fact, I've received some documents that suggest the opposite. The handout yesterday outlining the current debt collection practices that UC Health claims to use. There are 16 steps before they go to court. And the chart they gave me emphasizes that, like, how rare it is that they actually get to that point. And they emphasize that there's near 100% collection rate without having to resort to that wage garnishment. All right. UC Health can afford to stitch their name into the jerseys of the Colorado Rapids. I am not sure how any of this suggests that wage garnishment is necessary. Regardless, I have not been provided with any financial analysis, revenue models, or single page of data showing that without wage garnishment any provider's financial viability would be threatened. Again, I just think about how is this working in Texas. This is the law of the land there. I do not understand how in this environment, when our constituents are screaming at the top of their lungs for relief, that we cannot match those protections. I've also heard that this is a tool that's very rarely used. And if it's so rare to be exceptional in your practice, then by definition it cannot be central to the business model. You do not need it to keep the light on, and you are not fighting for it for operational necessity. We cannot preserve a tool that is being used as a weapon that reaches into a single mother's paycheck because of a billing error she had no part in making and no way of discovering. And for the people on the other end of Colorado's 14,000 garnishment orders a year, this weapon is devastating. UC Health is a $6 billion health system. It's the same institution whose name hangs from the rafters of the ball arena and it's stitched into the jerseys of Colorado Rapids. They have the financial capacity comfortably to absorb a policy change that says you cannot reach the wages of a mother of three who works at a gas station to collect an $881 emergency room bill from four years ago. You cannot put a lien on a home of someone whose family who has a quarter million dollars in debt, most of it from a billing error. I want to close with something I know to be true about every person in this room. I know every one of us has stood up at town hall and been asked about health care, and every one of us has said some version of the same thing. We hear you. We're fighting for you. We're doing everything we can to make the system better. Let's show people that we mean it. I suspect most of us support policies that are more transformative than the ones that are in this bill. Most of us probably support a policy like Medicare for all. And most of us would like to live in a world where no one loses their home. All of us would like to live in a world where no one loses their home because they got sick and the billing department failed to file the right paperwork. But we keep waiting for Congress to act. We don't have to wait for a federal fix that is not coming. We are not powerless. We can listen to the impacted people who are coming here today telling us this is urgent. We have a clear model in Texas, a conservative state that refused Medicaid expansion, showing that protections like this won't put providers out of business. Again, it's not our job to get the lobby to neutral on our bills. It's our job to pass legislation to help our neighbors. Texas does this. It's time for Colorado to do this too. I'll also note we're still willing to continue working on this policy. There are changes that I've talked about with members of this committee in the strike below that we want to work on. I would just like to be a state where medical debt doesn't mean somebody could lose part of their paycheck. And with that we ask for a yes vote And thank you for bearing with me I worked hard on my remarks Thank you sponsors Questions from the committee Representative Ryan Thank you Madam Chair Two questions. The first one is, can you tell me more about how the bill, as amended with the strike below, addresses accountability for hospitals? I'm guessing that's on page 4 and line 28. Maybe it's where that starts, but I want to know if I'm missing something. and how you envision that would happen because I think that's definitely a problem, right? And maybe we'll hear some testimony about that later, that there is a billing error or something like that and then it does go through the collection process and then it drags that individual through the court process that was unnecessary to begin with. So walk me through operationally how that would happen if there was an error. Representative Justin? Representative Miley. Thank you. So, yeah, that is the enforcement provision that we have in here. And I appreciate that you've raised this point, right, because we're talking about, you know, the vast majority of these collection actions being initiated by institutions that have billions of dollars in revenue. And what we put in here is a liability for $3,000 in actual damages sustained as a result of non-compliance. When on the other end of the coin, which is this is an important part, I think, of this bill's framing in general, right, is how our legal system treats different parties differently. On the other end of the coin, what working class people are facing when they're in this situation is loss of home, loss of job, loss of car, a complete end to their life as they know it. And here we've put modest liability in place on attorney's fees. Representative Joseph. Thank you. To Representative Mabry's point, that also there's equitable remedies as well as part of an accountability within the bill, which is line 34 to 35. Representative Wright. Thank you, Madam Chair. Just a follow-up question on that. So what is the current process if there is fraud or not fraud, pardon me, if there is an error on the hospital part and the patients are even dragged through this? Is there any remedy currently? Representative Mayberry. Yeah, thank you, Madam Chair. I'm sure there are many remedies in tort law. You could probably bring an unfair and deceptive trade practice claim under the Consumer Protection Act. You might be able to bring a claim about misrepresentation or negligence or something like that. But that's complicated. You have to find an attorney who has the capacity, the time, the willingness to do it. And I think it's really hard for working class people to just readily be able to find an attorney who can take on a medical debt collector or a hospital. Representative Wright. Thank you, Madam Chair. Third follow-up question to that. But if this were to pass, wouldn't they still have to do that in order to recoup those $3,000? Yes, they would. Sorry, Madam Chair. Representative Wright? So they still would have to find a lawyer. There's no easier way to get them to recoup that? Representative Maywee. if you have ideas on how to make the enforcement of this bill stronger I would love to accept them but you know we trying to pass a bill that responsive to stakeholders and they saying that this in here is already too much If you have ideas on it being stronger happy to hear them But, you know, I think access to justice is a fundamental problem in our legal system that's inherent and one we need to address more broadly.
Representative Johnson? Thank you, Madam Chair. Permission to dialogue with the sponsors?
Permission granted.
coding system we have in the state, along with the way our hospitals are operating in them, it's just not feasible to match a state for state. It is working for Texas. It's very hard in Colorado to operate because we have Title X. We have Title XII. Their statute starts in the 400s, and it addresses things in a different aspect. So trying to compare the two, what we found out with much stakeholding wasn't working. And looking at this, while I understand the intent because medical debt is very expensive, it is hard for patients. My fear and what I've told, you know, looking at this avenue, I don't know if it's the correct one. Have you talked with rural hospitals when they're operating on a three, four week margin? I have rural hospitals that are going to go under. So if they're not receiving payments, they can't operate. And what I fear is for the patients who do have the medical debt, that is a better option than having no medical option at all. So I just want to know if you've heard that feedback of this is going to very much strip away a lot of what the medical sources we have in rural Colorado, and it's going to be forcing a lot of these patients then to come to urban areas.
And your take on that. Representative Mabry, and then you can dialogue. Thank you, Madam Chair. Thank you for that question. So the first part of your question about Texas's statute, Texas's code, it not being feasible. In Texas, you have a constitutional right to not have your wages garnished. That's just fundamental. And I don't know that there's any coding or statute that matters to that specific piece of the law in Texas. I have heard of rural providers not liking this bill, being concerned about it. We have stakeholder extensively, and we've had a lot of conversations. And what I have asked for is any sort of indication whatsoever. Open your books. Show us that this tool, that taking people to court to garnish their wages is essential. And where does that fall in the three, four-week margin that you're talking about? How much money are they actually generating from garnishing the wages of people for medical debt. And I think it's also important, and I know you will appreciate this, it's also important to keep in mind that our neighbors in rural communities make less money. And so if their wages are getting garnished, already, already, I'm skeptical that this is a fundamental piece of the budget of any provider. But if you in rural Colorado and you talking about garnishing somebody wages in rural Colorado it is likely that you not getting that much in the first place But think about the impact on the person This is why I wanted us to think about the autonomy of people which is maybe why in the Constitution in Texas, they say we're not going to take away people's freedom to decide how to spend their own money and manage their debts. We're not getting rid of debt collection. We're not saying you can't get a judgment against you. This is about wage garnishment. And I do appreciate where you're coming from. Since we are in dialogue.
So my pushback would be, though, is without having that enforcement mechanism, the garnishing. We have, and we see them in all medical, a lot of folks that will go visit many areas multiple times, high, you know, visit patients. And if there is no enforcement piece, where is the whole, the accountability that they're not just driving up this debt on our hospitals, our providers? And they don't have any fear then that there's not going to be anything back. There is the double-edged sword of debt collections. You know, they have that game because you do enter a contract in Colorado, the no surprise law. You sign all these forms, not that anyone ever reads them, but you legally sign and bind yourself that you've read for no surprise billing. You've entered this contract to receive the service. That's where the medical debt comes in if you don't fulfill that contract with the medical to fulfill the service. But the medical debt collectors only have so much teeth. that's where it then goes to the courts. We take the teeth away. Who's to say then we don't crumble our whole medical industry because there is no enforcement piece and people don't feel like they have to pay their debts entering these contracts?
I think Representative Joseph, you wanted to comment on one of the... Sure. Thank you, Representative Johnson, for your comments. I was taking some notes as you were talking about rural hospitals and the stress being put on rural hospitals and its impact on urban areas. And I think that's a very real, real fear. As someone who works as an attorney, and I've worked mostly in urban areas, but I've had colleagues who talk about the stress on rural areas, the lack of services. But also to the same point, I feel like in essence, in your question, almost as if we're pitting rural hospital against rural constituents, right? Because at the end of the day, what we're trying to do is protect constituents from increasing medical debt. And when you have someone's wages being garnished and their property is having liens on it, you are pushing the person over the edge. That constituent of yours who live in rural areas are being pushed over the edge because of medical debt. So that's what we're trying to do is ensuring that they are protected. And again, as you know, in this bill, it's $5,000 that is being protected, not $15,000 as in the original strike below or $30,000 as in the original bill. And also to the point that I wanted to make to what you mentioned about, again, we just have to think about the issue a little bit more broadly. For instance, if you were saying, okay, we need to ensure that, you know, hospital are collecting because we don't want them to go out of service for constituency because it will certainly impact our urban areas. But it's the same thing, too, when you think about pushing a family, a mom and dad, into the brink of bankruptcy in those rural areas as well where there is a lack of social services for these community members as well. But ultimately, it is society and the rest of us who pay. When a family finds themselves living in their car, which we have in Boulder families living in their cars, because of medical debt, it is the rest of us who has to pay. So in essence, this particular bill, we're ensuring that families are protected. And we are not, again, as we've noted in this particular bill, it is not a bill that is, yes, it is an important bill to our community and to our constituency, but the bill is so nimble, it's so thoughtful based on the stakeholding that we've had over the last couple of months. And I'll stop right there. Thank you.
I do just want to direct you. I would like to directly respond to your question. So we are not taking away all the teeth. This chart I was given yesterday by UC Health shows 16 steps, all legal. You can send somebody a financial assistance letter. You can send somebody a second letter. You can send somebody a statement. You can call people. You can send people to debt collectors. You can still sue people for medical debt, right? What we're trying to do, and again, we're willing to continue to work on this policy, but what we're trying to do, I think, three core principles, your last $5,000, your home, and your wages. People have more stuff than that. What if you are going to get a lien on your car? Also, people don't want to be taken to court to have to fight this stuff and prove that they only have $5,000 anyways. People don't want to get to that point. When you get a letter threatening to take you to court, you are likely to pay. And I also believe that our neighbors want to pay their bills. I know you believe that too. Our neighbors want to pay their bills. And when they have the money, they do pay their bills. And Texas is the example that I keep pointing to because 30 million people live there. A lot of them are rural. But there are four other states in addition to Texas that do this. and that collection can still happen there.
Okay, additional questions from the committee. Representative Boog. Thank you, Madam Chair. And thank you for the presentation. Does the bill distinguish between those who are truly vulnerable patients and then those with means who could pay their bills and might game the system? Representative Mayberry. Thank you, Madam Chair. So we have done that through the asset part of the bill. The initial draft of the bill had accounts that people who have means are likely to have, that working class people are not likely to have. And we've lowered the amount in your bank account to $5,000 from $30,000. On the wage piece, the reason why we're not putting a cap on the wage piece is, A, debt collection actions that lead to wage garnishment almost exclusively happen for low-income people. Again, people like to pay their bills. People do not want to be in debt. Texas has no cap. It's a constitutional right to not have somebody else reach into your finances and tell you how to manage your debts in the state of Texas. You do not get somebody else impacting your economic autonomy like that in the state of Texas. I think it's also important to recognize when people are in these situations, maybe they were higher income earners. I think about some rep winner often talks about AML winner often talks about roughnecks people who are doing blue jobs where they might make a decent salary What if they get hurt on the job Are we going to look at that decent salary that happened right before they got their injury? I think if it can happen in the state of Texas where wage garnishment isn't an option here and there's no cap, I think we can have that work in the state of Colorado. Representative Hamrick. Thank you, Madam Chair. Thank you for bringing the bill. My question, a couple questions. One, do you have statistics on the percentage of debt that originates from the large hospitals in the metro area that you're talking about? And the second question is the foreseeable impact of your bill on small health care spaces and private practices? Representative Mabry. Thank you, Madam Chair. I don't, but what I would say is I would counter that and say, can we get any sort of evidence whatsoever from any provider at any level that talks about how much of a percentage of their business and revenue comes from debt collection in court? That's, I think, the important question for us to consider. And then also just the fact that, again, and I will just keep reiterating it, I don't think Texas or any of these other states are the moon or Mars and things work upside down there. Their economic systems are pretty similar to ours. And I would argue that Texas' health care system is at a disadvantage to ours because they did not expand Medicaid. And so I don't know what's unique about Colorado that some of these things can't work here. Representative Johnson.
Thank you, Madam Chair. I just wanted to attempt to respond to Representative Hemrick's question and to add to Representative Mabry's feedback here. We did offer a fact sheet that we did share with you that talks about the estimated 26,846 medical debt lawsuit were filed in 2024 in Colorado. And also some of the top common plaintiffs are UC Health with 3,481 cases filed and Collection Center Inc. with 9,000 cases, Credit Service Inc. with 12,000 cases filed as well. So again, half of all those cases are for less than $1,800. $100. So again, if you consider that and you put all these numbers together, it is millions and millions of dollars that are being requested or collected from our community members. And I'll just briefly say, sorry, I know we're trying to get to where this is. I'll just briefly say the family physicians support this bill now with the strike below, and you will hear from providers who will speak in support of the bill.
Representative Biden. Thank you, Madam Chair. Can you talk more about threats for deportation and kind of what you were hearing around that? And if that's going to come up in testimony, that's fine too. Representative Mabry. Thank you, Madam Chair. I honestly have not heard a specific story about it. I think it's important to just enshrine this in law, and maybe we will have testimony about it. Representative Joseph. Thank you Madam Chair I have to share with you that I have personal experience of seeing getting a copy of a release from a doctor office that I been to and where they put it that they will cooperate with law enforcement Yes.
Representative McCormick. Thank you, Madam Chair. I was just curious about the initiating or threatening to initiate a collection activity against an individual who is not a patient. I just need to help visualize who that is happening against that's not a patient.
Representative Mabry. It could be like a guardian situation or a, and we will have experts to speak on this, but I believe what we're getting at here is if they're asserting that you're responsible for somebody else's debts. So like your partner or your spouse.
Representative McCormick. Yeah, just to follow up, because your definition of patient does include guardian, so I guess it would be someone else besides the guardian.
It would be like a spouser. I will ask one of our experts and can acknowledge it during closing, or one of them can come. Okay, thanks.
Emma Winter. Thank you, Madam Chair, and thank you, sponsors. As we make this comparison between Texas and Colorado, I mean, are you factoring in that we have minimum financial assistance policies and other protections like hospital discounted care?
Representative Maybridge. I believe that they have made the right decision in determining broadly that it is a violation of somebody's rights under their constitution to have somebody else reach in their finances and tell them how to deal with their debts. Just as a principle, like as a value, I think they have gotten that correct. And I'm glad that we have extra programs to help people pay. I would argue, like I said in response to Rep Hamrick's question, that those things make it easier to be able to deal with the fact that we might not have wage garnishment if you're a rural provider in Colorado because we do have all these assistance programs that they might not have in Texas, which means there's probably more sources of funding, notwithstanding the fact that we might not allow for wage garnishment.
Representative Johnson. Thank you, Madam Chair. And so I just want to make sure I'm hearing correctly from the sponsor that you're saying that, like, the government can't come into someone's wallet and say how they spend their finances. And if that's the case, I see you shaking your head. Unlike Texas, Colorado has Tabor that we see keeping to be attacked when they should have their own access to money. So it just seems like a misdirection of information when we say they should have access to their own wallet money, but we do other things in this place, and we're still not holding accountable for, you know, the whole thing on the debt that I want to point out is there are gaps. There are reasons that there are debts that are getting lost or over. I firmly believe this is not the answer. There are other ways to hold it accountable, but to keep comparing to Texas and saying this, but then knowing that Texas doesn't have Tabor, and we do, we have vastly different financial structures, health care structures, Department of Insurance structures. It is comparing apples to oranges, and we can't do that in individual states.
Representative Mabry. Well, I don't think that conversation is necessarily to the bill, but what I will say about that is that what you are talking about is a relationship between the government and people as citizens as taxpayers What the Texas Constitution is about is about the use of the court system between two private entities to empower one private entity or one person to get control over how another person deals with their finances that as a principle I think is different than paying taxes.
Representative Johnson, one more quick question. We have quite a lot of witnesses so we want to get to that. So one quick question. And my question then looking at the Texas model is what percentage of them are private hospitals versus public hospitals? And do you know what the difference is in Colorado between private and public if we're going to get into private and private?
Representative Mayberry. Thank you Madam Chair I am not sure but I would just refer back to my question or my response to Rep Winter I would argue that all providers, for profit non-profit are probably in a better position to handle something like this in the state of Colorado because we've expanded Medicaid and we do have more assistance programs so I don't know what the breakdown of that is but I would assume that this is a small part of doing business in the state of Colorado, getting to somebody's wages in the first place. At least that's the information that we've been provided. Nobody yet has provided me information that suggests this is a fundamental part of somebody's business regardless of if they're a for-profit or a non-profit.
Amo Winter. Thank you. Rep Mabry, when was this put in the Texas Constitution?
In the 1980s.
Thank you.
Vice Chair Leader. Thank you. Mine's real quick. Since Tabor was brought up, we are the only state that has that, and we need to repeal it. But my question is, can I get one of those fact sheets? Representative Joseph. Thank you. Okay. Any additional questions from the committee? Seeing none, thank you sponsors. We'll move on to the witness testimony. Okay, let's bring up our first panel. Nina DeSalvo, Annie Martinez, who is virtual, and Gabriel Liao, Kathy Sullivan. Okay, we're going to go ahead and get started. We'll start from my left to my right. If you can introduce yourself, the organization you represent, and you have two minutes. And there's a tiny little button right by the plug. So if you want to go ahead and push that, and you can get started. Please proceed. I think it's not pushed yet. It'll turn green. Good afternoon. Good evening, Madam Chair and members of the committee. My name is Gabriel Leal, and I live in Boulder, where I grew up. I'm currently a student at CU Boulder, studying molecular, cellular, and developmental biology with plans to pursue medical school. And I'm here today in support of House Bill 1267. I grew up with parents who fought so hard to give me and my three younger sisters a good life. I have so many memories of me and my dad having wonderful conversations as we rode bikes together on the way to school. My mom was there for us in so many ways, supporting me in my advanced placement classes and my interest in the violin. But alongside these positive experiences, the impacts of medical debt were a constant source of stress and anxiety. As a very young child, I remember debt collectors knocking on our door. It was terrifying because those very loud knocks usually came at night, and I hadn't realized our family's medical debt started when my mom gave birth to me. When I was born, my mom had private insurance through her job in the legal field, but the co-pays were so high, which meant the bills just kept piling up. The debt grew bigger when I was three years old, and I had emergency surgery for a life-threatening infection on my ear. Eventually, my mom was sent to collections, and her wages were garnished, so she had to take high-interest payday loans to try to fill the gap because what was left in her paycheck was not enough to pay for food, diapers, our electricity bill, and our rent. She still has some of that debt today. Around eight years old, I learned what the word eviction meant because we were on the edge of being kicked out of our home. The idea of landlords throwing us out with all our belongings was almost unimaginable. I wondered where we would go to be safe and how we would stay together. Our electricity was cut off several times, and we rarely had enough food, even though we visited food banks. I'm 19 in college, and instead of building security, my sisters and I are carrying the weight of medical debt. It doesn't have to be this way. Colorado already has laws to protect children to keep them safe, fed, and in stable homes. House Bill 1267 does the same for medical care. Protecting kids from medical debt is just common sense. Please vote yes. Thank you so much for your testimony. Please proceed. Thank you, Madam Chair and members of the committee. My name is Nina DeSalvo. I'm an attorney and the policy director with Towards Justice, and I'm here today to encourage you to support House Bill 1267. In addition to Towards Justice's litigation and advocacy work, we run a legal intake program that served approximately 1,100 people last year. Many workers reach out to us because they've been victims of wage theft. In one case, we found that a concern about wage theft was actually related to a wage garnishment for medical debt. The fact that this worker did not know that she had been sued for medical debt, that a default judgment had been entered against her, and that a medical creditor was now garnishing her wages undermines so many of the claims that you all have heard from hospitals and other medical creditors. That is, no one worked with this person to figure out how she could pay off these medical bills. No one explained to her what she owed and why, much less the court process or the consequences of default. Instead, these creditors just started taking money out of her paycheck, making negotiation impossible and causing extraordinary financial insecurity. Garnishing the wages of people who cannot pay is not a money-making strategy for medical creditors. It is a strategy to disincentivize the working poor from seeking medical care. And this bill would not allow it. Instead, this bill, as amended, would allow medical creditors to take money owed out of a patient's bank account when that patient has more than $5,000, ensuring that if the person can pay, the medical debt can be collected. There is no need to garnish someone's wages or to place a lien on their home. And banning those inappropriate collections actions will incentivize medical creditors to do what they say they do already, to offer payment plans and help people pay within their means Studies show that collecting in that way works far better and achieves repayment more effectively than foreclosing on a home or garnishing wages So these protections end up being a win-win for both creditors and debtors alike. I urge you to support House Bill 1267. Thank you so much for your testimony. Please proceed. Thank you, Madam Chair and members of the committee. My name is Kathy Wood Sullivan. I am a member of Center for health progress and I live in Denver. I'm urging you to vote yes on Bill 1267 because we need more protection from predator debt collection agencies like those that has caused me devastation for me and my daughters. The nightmare started when my husband got sick and passed away and my daughter also ended up in the hospital. UC Health told me that Medicaid and Medicare would cover costs so I went about my life dealing with my husband's death and supporting my daughters and their grief. It was a lot. Then the notice started. I got a letter from UCL about a bill for my late husband and my daughter's care that I did not know that I owed. I took off time of work to go to the hospital to try to resolve this issue. They told me that there was nothing they can do. I wanted to pay the bill and they did nothing to support me to help me. In January 2017, there was a knock on my door at 10 p.m. at night from a debt collection agency telling me that I was served with court documents for my wage garnishment. They were taking me to court March 2017. I reached out to the third party collection agency and told them that I can only make a $50 monthly payment to pay this debt off. They said no. Devastation. I went to the legal aid. They negotiated on my behalf. Finally, after one year securing a $50 payment plan, but the collection agency failed to uphold their end of the deal. Somehow my balance kept going up and I spent hours on the phone with them. I did not have time for this. I was a single mom working 60 hours a week. The only choice that I had for peace of mind and to protect my family, to sell my late husband's wedding ring, to avoid my wages being garnished. Thank you for your testimony. I appreciate you being here today. Okay, we'll move on to online. Ms. Martinez. Good afternoon, committee members. My name is Annie Martinez. I'm an attorney with a doctorate in public policy and administration, and I'm here on behalf of the Colorado Center on Law and Policy, a statewide anti-poverty organization. in strong support of HB 26-1267. I want to address a few of the arguments you're likely to hear from the opposition tonight. First, you'll hear that tools like wage garnishment are only used in the most extreme cases, but somehow you will also hear that without those same tools, providers will not be able to survive, which is it. They cannot be both rare and essential. You will also hear scare stories that wealthy people will come and get care and refuse to pay and walk away untouched. And that is simply not true. This bill is carefully tailored. If someone wealthy chooses to not pay a medical bill, creditors can still get a judgment. And if that person has multiple properties, extra vehicles, a jet ski, or more than $5,000 in a bank account, collection options will still exist. What this bill does is protect working people from the harshest and most destabilizing collection tactics over medical debt. The most quote-unquote extreme measure in our bill is no wage garnishments for medical debt, something that the woke left state of Texas has enshrined in their constitution for almost all debt, not just medical. So let be clear that banning wage garnishment for medical debt is not some radical idea In addition to Texas Arizona California Florida Carolinas Pennsylvania also have their wages protected from garnishment for most debts. The principle is simple. Working people should be able to keep what they earn. Rather than try and set restrictions based on income, which can be burdensome to determine, the bill has been amended after rigorous stakeholding to protect the average working class Coloradan, someone who might own their home, their car to go to work, and a modest savings account for emergencies without creating an unworkable process for creditors. The reality is that these extraordinary collection actions are predatory and trap people who are already struggling and strip them of any real bargaining power. This bill will help restore that balance and create more opportunities for realistic payment plans. And no, this bill does not solve the cost of health care, but it's not meant to. Coloradans should not have to wait for the health care system to be fixed before we stop taking their wages, their property, and their stability over medical debt. Thank you. Thank you so much for your testimony. Questions from the committee? seeing none thank you so much for your participation today we really appreciate you oh i'm sorry if vice chair leader has a question i apologize sorry about that i just would like to know if you were finished with your statement if not please complete it ms sullivan the only charge for my peace of mind i don't think your microphone is on there you go okay The only charge for my peace of mind and to protect my family, selling my late husband wedding ring. I knew that if I didn't do this and the wage going came about, I would lose my home. As a widow and raising two teenage girls, it was hard. This was a traumatic experience last year when 18 really hit me. I was fearful of my life. I refused to go to ER because with the traumatic impact that I've had previously, I didn't go. What started as a building area caused my family devastation. There are so many of us like me. Please vote yes. Thank you. Thank you for your testimony. Representative Hamer. Thank you, Madam Chair. This is for the person on the wall. You mentioned that there are collection options other than wage garnishment liens and sort of taking assets $5,000 or below. What are the other options? Ms. Martinez. Yeah, of course. So if you do have accounts that have more than $5,000 in them, those are still accessible in a judgment. So if a creditor took an individual to court and a judgment was ordered, they would be able to collect against bank accounts that have over $5,000. In addition to that, there are manners of ways to file documentation in cases that would allow you, if you can't do it, a bank account, you can go after someone's property. Like, they're doing it now, right? So what we're saying is that that primary residence and, like, those primary personal property things that you need, like your car to get to work, those shouldn't be touched. But if you are privileged enough to have other things in your life, well, then you're going to have to sell that jet ski to pay off that medical debt that you didn't want to pay when you were at the hospital. Right. So this doesn't create this path that folks think of there being no teeth at all for any types of collection. What it does is insulate the types that the most vulnerable working class people in Colorado actually have, which is a month and a half worth of money in the account in case you get laid off or you have a kind of emergency where you can't pay your rent and your bills. Hopefully you've got a month and a half worth of that saved up. Addition to that is your wages which keeps food on the table and your home and your car right These are the things that people need to contribute to the economy to be part of our community and our society Those are not things that should be taken away from them to be able to pay off debt that they didn't want to go into. I think the part that we're also missing out here is that these are essentially hostage captive audiences. This is not a Victoria's Secret card or a lease at a BMW dealership. This is medical debt that people incurred to try to keep themselves healthy and to stay alive. And so treating them differently makes sense. It's just logical. But yes, there are other actions that can be taken. There's other types of property that can still be, you know, garnished against. Okay, additional questions from the committee? Seeing none. Thank you so much for your participation today. Okay, we'll move on to our next panel of support. Sophia Hennessy, Dr. Lynn Orphanhal, sorry, I can't read the writing, Ashan Kualra, and Bethany Pray. Okay, we'll start from my left to my right. If you can introduce yourself, or did you, I just saw you point, are you sure? Okay. We'll start from my left to my right. If you can introduce yourself, the organization you represent, and you have two minutes. Good afternoon, Madam Chair and members of the committee. My name is Ishan Kalra, and I'm with the Pew Charitable Trust, testifying in support of House Bill L67, because this bill is about providing essential protections to patients sued for medical debt. An estimated 27,000 Coloradans are sued for medical debt each year, and the number of lawsuits being filed across the country is increasing each year as well. The vast majority of cases are filed by third parties whose names are unrecognizable to the patients that they are suing. When patients are unsure if their lawsuit is real or even if they're geared towards them, they often don't engage in court processes, and they automatically lose their cases. across the country, an estimated 60 to 70 percent of all cases end in default judgments, leaving patients susceptible to garnishment. This legislation requires plaintiffs to provide the names of all the creditors who are associated with the medical debt so that patients can better understand who is suing them. It also ensures that patients don't get pushed into financial ruin because their wages have been garnished or their bank accounts have been drained. It only makes sense. people need to be able to maintain their livelihood so that they can manage paying off their debts while still affording their everyday needs. One medical scare shouldn't be able to push Colorado patients to the brink of bankruptcy. Many states have recognized this, and just last year, Rhode Island joined the four other states who ban wage garnishment from medical debt. The legislation also creates a self-executing or automatic bank exemption set at $5,000. Thirteen other states have already created automatic exemptions, recognizing that patients are rarely able to receive protections intended for them if they must come to court to claim them. To be clear, this bill is not about getting patients out of what they owe. It's about making sure that they understand what they owe and who they owe it to and are not pushed into further distress. Thank you so much for the time. Thank you for your testimony. Please proceed. Thank you, Madam Chair and members of the committee. I'm Bethany Prey. I'm Chief Legal and Policy Officer at the Colorado Center on Law and Policy, a statewide anti-poverty organization that advances the rights of all Coloradans. I'm asking for your support today on House Bill 1267. This policy with the strike below bars only those collection methods that are most destructive to a household's economic security and well-being and that are here termed extraordinary. Many providers never pursue extraordinary collections. Those who do, in recent history, that's primarily nonprofit hospitals and UC Health, can and should use routes to reimbursement that are more humane and support patients' health. One such route is hospital discounted care, which requires screening for public programs for uninsured households and provides a structure for manageable payment plans. Unfortunately, too many patients never know what they qualify for. State data shows that state screening data was not submitted or a final determination was unavailable for more than 150,000 patients in the last reported year. That's a lot of potentially eligible Colorado patients falling through the cracks. How many of them ended up in collections or having wages garnished, we don't know. If wages are garnished, chances are good, according to ADP data, that they had household income between $20,000 and $60,000. These are not rich folks. We want hospital discounted care to work better for patients and hospitals, and that's why CCLP and other organizations came to the table and collaborated with the Hospital Association on Senate Bill 24-116 to help hospitals enroll patients more quickly in Medicaid. We see the value of those screenings. If screening were universal or even close to universal, I might be persuaded that there are circumstances where these aggressive methods are needed, but we're tens of thousands of patients away from that. Because of the one big beautiful bill act, we face as a state the specter of many more people shut out of coverage. Sending people to collections, garnishing wages, having attorneys tack on fees and court costs that cause debt to balloon, that is not the way to go. Enrollment in public programs and making best efforts to get people into payment plans, that's what's going to work for Colorado. Thank you. Please proceed. Thank you for having me, Madam Chair, and the committee. My name is Dr. Lynn Orfali. I'm a resident physician in surgery and a member of the University of Colorado House Staff Association, which is the union representing hundreds of resident and fellow physicians across the Denver area. Before med school, like many in this room, I found myself in medical debt that got sent to collections. The tactics that the debt collectors used sound all too familiar to the ones being discussed today. The financial hardship I was already in was exhausting and all-consuming, and the actions that the debt collectors took were so invasive and far-reaching that even sitting here today I can feel how small and helpless I felt back then. The amount, by the way, that I owed that turned my life upside down for three years was $3,000. I owed this due to an erroneous bill that was sent to the wrong address. I am now fortunate to be on the other side of it, but I know that as my colleagues and I devote our lives to taking care of people, we are sometimes inflicting that same financial and psychological harm onto the patients that we all took an oath to protect. Debt does not deter people from seeking care. It deters them from seeking it early when interventions are cheaper and more feasible. Instead, they present later once their problem has become urgent, expensive, and complex. any doctor and they can tell you about not being able to provide appropriate care because the patient couldn't afford it despite the programs and protections that are in place as has been discussed. Or they can tell you about going above and beyond, sometimes putting themselves at professional risk in order to do the right thing by our patients. Early access to appropriate care is more affordable to the whole system and this bill moves us in that direction. It also alleviates a cost that you don see in a budget report which is the moral injury healthcare providers sustain from this part of the job which directly contributes to burnout and workforce shortages Protecting patients protects the people who are providing for them as well And to those claiming that providers universally oppose this I am a provider and I support it. The House Staff Association supports it. The opposition largely comes from people who are not on the front lines watching patients realize their financial ruin in real time or seeing them come back sicker because they waited too long. My colleagues and I took an oath to do no harm, and this system buries patients in debt violating that oath. I urge you to say yes. Thank you so much for your testimony. Please proceed. Good evening, Madam Chair and members of the committee. My name is Sophia Hennessy, and I'm the Policy and Research Lead Coordinator at the Colorado Consumer Health Initiative, a nonprofit dedicated to ensuring all Colorado's have equitable access to high-quality, affordable health care. I'm here today to express CCHI's strong support of House Bill 1267 and ask for your yes vote. This bill will make important strides to ensure that needed medical care and the compounding effects of rising health care costs do not continue to have devastating impacts on the finances and well-being of the people across Colorado. Through our consumer assistance program, we know previous medical debt legislation is working for some people. But like my co-panelists said, many still slip to the cracks. The Medical Debt Protection Act is aligned with common-sense measures implemented in other states. We have heard concerns from providers about the bill's effect on bottom lines. However, we have not found evidence that medical debt is an important revenue source for health care providers. Colorado's Hospital Financial Transparency Report shows many independent hospitals writing off debt at the same or greater rate as they provide charity care. Further reporting tells us that providers sell debt off a fraction of a cost, pennies on the dollar. The limited information available on wage garnishments suggests they only contribute 0.1 to 0.2% of providers' total revenue. All this begs the question of what providers can really get out of using extreme collection actions to collect on medical debt. When we look at the wage garnishment data available, we see people who work at Walmart, Amazon, and other blue-collar jobs. We want our providers to be financially sustainable, of course, but not at the expense of taking away patients' livelihoods. House Bill 1267 does not get rid of medical debt. It does not stop medical billing, but it does protect homes and wages for ourselves and our neighbors. I urge your yes vote. Thank you for your consideration of my testimony, and I'm happy to answer questions. Thank you so much for your testimony. Questions from the committee? Representative Hamrick. Thank you, Madam Chair. This is for the woman that mentioned the hospital discounted care and screenings. Is that mandated now on providers? must they give this program, the information of this program, to people that are incurring debt? Ms. Prey. Thank you, Madam Chair, and thank you, Representative Hamrick. The hospital discounted care applies to hospitals and to practices that are under hospital licensure, so it's a little broader than hospitals. And it is a program that requires that that information be shared. There is some data actually from my partner organization, CCHI, about how thoroughly websites actually demonstrate how you can access hospital discounted care, and there's some holes in that. So generally speaking, it is an obligation to make sure that patients know about it. Vice Chair Leader. Thank you. This question is for you, Sean. So how does this bill compare with protections already available to debtors in other states? Thank you for your question Representative Leader And to answer your question I first start by talking more about Colorado protections So the National Consumer Law Center ranks each state garnishment protections Colorado currently ranked as a D Current practice, debt collectors are allowed to seize 20% of patients' wages, and there is a $2,500 bank exemption. However, it's not self-executing. What that means is it's not automatically applied. consumers or patients in this case must come to court in order to be able to do that. So Pew has conducted research across states. One of the states that we have great research for this is Tennessee. Tennessee has a similar provision where there's a $1,000 bank exemption, again, not self-executing, and fewer than 1% of patients actually claimed that exemption. And so, in fact, that protection is not being used as intended. You mentioned other states that have similar protections. One of the ones that was talked about before me was Texas, but there are other states that have also banned wage garnishment for medical debt. Those include Pennsylvania, Rhode Island, South Carolina, North Carolina. And then there's also 13 other states who have passed self-executing bank garnishment protections. Those include Delaware, which protects all the money in a patient's bank account, as well as Wisconsin, which protects $5,000. Any additional questions? Okay, seeing none, thank you so much for your testimony. We appreciate you being here. We'll bring up the first opposed panel. So we'll start with Allison Morgan, Charlie Shoup, Blake Boettcher, Scott Kennan. Kennan? Are any of those folks? Oh, here we go. And then can we also call up online Mr. Stephen Johnson, Zach DeAragon, and Aaron Bohannon? Okay, we'll start. Any of those folks online? One person? So let's call up, in addition to that, John Conklin and Mary Erickson. Okay, we'll start from my left to my right. If you could introduce yourself, the organization you represent, and you have two minutes. Thank you, Madam Chair, members of the committee. I'm Allison Morgan with the Colorado Bankers Association, and I believe this is my first time in front of the health committee this year. At the outset, I'd like to say we appreciate the intent behind the legislation and the ongoing efforts to address the challenges surrounding medical debt. We've engaged in good faith through the Attorney General's Office to identify reasonable amendments that balance consumer protections with maintaining a functioning credit and lending system. However, the strike below amendment before you today remains overly broad and continues to include financial institutions in ways that we believe are not appropriate. Banks are not traditional medical debt collectors, yet the definition remains so broad, we are brought under the umbrella of a medical debt collector. Financial institutions operate under a highly regulated federal framework When it comes to lending and collections Laws such as the Fair Debt Collections Practices Act the Dodd-Frank Act of 2010, and Regulation F established strict requirements on how and when consumers may be contacted. Additional protections under the Equal Credit Opportunity Act and the Service Members Civil Relief Act further ensure fairness and accountability. Moreover, the Federal Deposit Insurance Corporation directly oversees and handles complaints related to debt collection practices by banks. This is a comprehensive and robust system that is already in place. The amendment also significantly raises the lien cap from $2,500 as established in Senate Bill 22086. This increase is well beyond the limit. I would ask for a no vote. Thank you so much for your testimony. Please proceed. If you don't mind just pushing the button right by the plug. Thank you so much. Good evening, Madam Chair and members of the committee. My name is Charlie Shoup, and I represent PFC USA. PFC USA is a Colorado agency that works alongside Colorado health care providers to help patients responsibly resolve medical bills. This bill shields Colorado's financially capable at the expense of Colorado's financially vulnerable. Our process is designed to maximize awareness, engagement, and collaboration so that consumers understand their obligations and can resolve them voluntarily within their unique financial circumstances. Voluntary resolution is always our goal. Garnishment is a tool of last resort. We only pursue legal action when our other efforts to engage fail. Even then, there are many additional opportunities for a consumer to resolve the account before garnishment, and the vast majority of our legal actions are. More importantly, we only pursue legal action when our data indicates a consumer has the ability to pay. We initiate legal action on less than 2% of accounts placed with us. We initiate wage garnishment on less than 1%. But that 1% matters because it creates an external incentive for consumers to engage in a real consequence if they don't. If we eliminate wage garnishment, there's nothing preventing a financially capable but unwilling consumer from avoiding their financial obligation to medical providers. Often it's only after we issue a garnishment that a consumer finally engages. Even then, we will release the garnishment in exchange for a voluntary payment plan at lower amounts than we could garnish. If the financially capable aren't held accountable, the cost doesn't disappear. it shifts in the form of higher health care costs for all patients, more upfront payment requirements, reduced services and access to care, and the people who feel those consequences the most are the very individuals this bill is intended to protect. This bill removes accountability from those who can pay, and it shifts the burden onto those who cannot. Thank you again for the opportunity to testify. I respectfully urge you to vote no on House Bill 26-1267. Thank you so much. Please proceed. Thank you, Madam Chair and the committee. My name is Blake Betcher with BC Services. We are a collection agency. We are not a garnishment agency. We are not a litigation agency. We are a collection agency. And unfortunately, litigation is a tool that we utilize only in the instances where individuals choose not to communicate with us. We do ample reach outs. We want to do everything that we can to work with patients. And really, my collectors are patient advocates. They help them understand our very complex health care system, which we've heard from both sides. And I think we can all agree on today. We help them understand deductibles, coinsurance, primary, secondary, Medicare A, Medicare B, Medicare D, all of those different things. My patients are trained on so that we can help make sure that we're not going to collect a penny from somebody that doesn't owe it. And as far as Colorado has done a great job of protecting the unable to pay, unfortunately, this legislation is going to protect the unwilling to pay. We've seen a lot of various bills throughout the last five years that really do protect it. And even in our agency, we've seen a 300 percent increase in provider charity write offs because we help identify that. and we then pass that information back to our collection or back to our clients. Lastly, I really do have a concern as a Coloradoan and as a father, if this goes through and there is no means of forcing that payment, this cost will shift to others, and then that cost will then be shifted even further up in the billing process. And that means when I take my kids in, it may say, okay, well, you have to pay for this. For my family, that means I'm going to swipe a credit card. And as soon as I swipe that credit card, I'm going to lose the ability to communicate with those billing offices to properly bill insurance. I'm going to lose all of those protections. 3% interest is now 30% interest. Credit card companies will absolutely find a way to get their money back in a much more aggressive manner, and this cost will shift up front. So thank you for your time, and I welcome questions. Thank you so much for your testimony. Please proceed. Madam Chair and the committee members, thank you for letting me speak. My name is Scott Kenyon, and I am the business director at the Women's Clinic of Northern Colorado. I am testifying in opposition to House Bill 26-1267. Our company employs about 150 people. We are the only OBGYN group to deliver babies at the Poudre Valley Hospital in Fort Collins. This bill would likely force us to change to a pay-up-front process. To pay up front, most patients would use their credit cards where they would have none of the already existing protections on our medical bills are treated, not to mention the high credit card interest rates. Unlike other industries, we don't set our prices. Our prices are generally set by a complex formula defined by Medicare, which is mimicked by almost all the private health insurance companies. When significant cost increases happen, we deal with that by reducing access and reducing staff wages. This bill forces health care providers to act as interest-free lenders, requiring long payment plans. In the retail industry, we see 0% financing all the time. You can buy a car or a diamond ring at 0%, but those retailers get to calculate the impact of 0% financing into their price. The health care industry, especially the small independent clinics, have no ability to do that. This bill introduces complex compliance requirements, including the threat of a $3,000 minimum for statutory penalty, exposing providers to costly litigation over minor technical errors, and makes them an easy target for unscrupulous attorneys. The total cost of defending against just one lawsuit would wipe out the thin margins of small practices, threatening our ability to stay open. This bill puts employee jobs our services and patient access to care at risk Please vote no on House Bill 26 And I thank you for my opportunity and I happy to answer any questions Thank you for your testimony. We'll move online to Zach de Argonne. Madam Chair, members of the committee, thank you for the opportunity to testify this evening. My name is Zach de Argonne, and I serve as the President and CEO of the Eastern Plains Health Care Consortium. We represent 15 rural and mostly frontier hospitals across eastern and southern Colorado, all who oppose this bill. We fully support protecting patients and the intent behind this bill. In practice, hospitals often spend six months or more working with patients through insurance resolution, financial assistance, payment plans before accounts ever reach collections, as you've heard from my peers here on the panel. We want to protect those pathways and conversation, and the concern is that this bill goes too far and removes meaningful tools of last resort, which make these conversations with our patients effective. For rural and frontier hospitals, that has real consequences to us and our patients. This bill limits the ability to distinguish between patients who cannot pay and those who choose not to pay when there's no expectation of repayment that directly increases uncompensated care. Those costs don't simply disappear. When care is not paid for, those costs are shifted across the health care system to other patients, employers, and increased insurance premiums. In rural and frontier hospitals, many do not consistently achieve even a 1% margin, and some operate at a loss in any given year. Even small increases to unpaid care can quickly translate into real decisions, reducing services or delaying investments from our hospitals. This changes how health care is delivered. Without the ability to resolve balances after care, that shift risks up front, leading to more payment required at the time of service, which can create further barriers to access, especially in our rural communities where patients often have to travel long distances and have fewer alternatives. Within our hospitals, pursuing patients is very rare. In a last resort, after months of working with them through financial assistance and payment plans. But having that last step in place is what allows our system to function. Without it, the ability to engage patients who have the means to pay becomes very limited, and these costs are shifted elsewhere throughout the healthcare system. We're not looking to pursue patients. We're trying to maintain access to care in our communities that depend on us and avoid limiting or shutting down services. We believe there's a path forward that protects patients while maintaining a balanced and workable system for our providers. Thank you for your time today. Thank you for your testimony. We'll move on to Mary Erickson. Hello? Hi there, we can hear you. Hope you're back on mute. Ms. Erickson? Hello? Hi, Ms. Erickson. Could you please proceed with your testimony? If you want to introduce yourself, the organization you represent, and you have two minutes. Sure. My name is Mary Erickson. I worked in the medical field for 50 years and I'm representing the small collection agency I own and members of my or what I want to say or in the medical field for 50 years. I administered health care care for many patients and financial assistance. I'm also representing a lot of my physicians that could not attend today because they would have to reschedule their practices. and in rural care a lot of our patients and citizens have to use EMT departments or drive over an hour hour and a half away to just to get to a medical appointment changing appointments can wreak havoc for these patients in need of health care this bill goes too far it shortens the time period for providers to resolve billing disputes and collect payment while also requiring mandatory reductions of patients balances in certain cases regardless of contractual agreements or insurance reimbursement expectations. It increases administrative burdens through notification requirements and limits standard collection practices, which will make it more difficult for providers to recover payment for services already rendered. In many cases, this shifts the cost onto providers, taxpayer, and rural ambulance districts that already operate on tight margins. Unlike other businesses, medical providers in Colorado already face strict limitations on interest rates, collection time frames, credit reporting, and debt recovery options. These additional restrictions further discourage private practices, particularly in rural areas where recruitment is already a challenge. Medical providers deserve to be treated fairly and consistently with other small businesses in Colorado. For these reasons, I respectfully urge you to vote no on House Bill 26-1267. Thank you. Thank you so much for your testimony. We'll turn it over to questions from the committee. Representative McClellan.
Thank you, Madam Chair. I have two questions, but I can just start with one if there's more people. I have a question for, I think it was Ms. Morgan from the banks. I was looking at the definition. You had said that banks are scooped up in the definition of medical creditor, and I just wanted to dig into that a little bit more. I think that's what you were saying. The bill has the previous definition was medical creditor means an entity that attempts to collect on a medical debt, including, and then there's list. And the new definition is a medical creditor means an individual or entity that claims entitlement to payments on a medical debt. So I wanted to know how a bank is getting scooped up in that, just so I can understand how that works. Ms. Morgan.
Madam Chair, thank you, Representative McCormick. Banks actually have medical debt loans. So we have purchased loans from some of the hospitals, even at the 3% rate. And so several of our members have on their books some of the medical debt loan. So under this definition, we would qualify as a medical debtor. And in our conversations with the Attorney General's office, they have agreed that we would fall under this umbrella, unwittingly or not, we would fall under this umbrella. But the loan, because it is owned by the bank, also falls under all of the federal regulations that I bored you to death with.
Representative McCormick. Yeah, and we can move on. Okay, thank you for that. My other question is for Mr. Kenyon. I heard that how this bill would impact the ability to provide services. You did explain that. I just curious to know how much since you are the I think you said you were the business manager how much of the revenue or the debt that you are in charge of collecting ends up in that portion of those patients that you have to take to court for wage garnishment. Like if you have a general percentage of all the folks that you go after to pay their bills, how much end up in that category?
Mr. Ken. Thank you, Madam Chair. Representative McCormick, I don't have the exact numbers, but I can give you some generalities if it's helpful. So first, the premise of why we do it in the first place. We're required by contract with the private insurance companies to make reasonable attempts to collect the patient co-pays and deductible amounts that they eventually tell us we are responsible to collect. And if we don't collect those amounts, then there's litigation on record that show that the payers come after the providers' offices for waiving those balances or not attempting to collect them in a reasonable effort and requesting all the money back under the contracts of similar patients that we were reimbursed under. So if we don't attempt to collect the debt, then we can be viewed as interfering and violating the contracts that we have with the private payers. With the government payers, it's actually worse. With the private payers, they just come after you for money. But if the government payers think that we're not doing the job correctly of attempting to collect what they tell us to collect, then we actually subject ourselves to criminal penalties for violating the federal and state guidelines for the government payers. So I can't tell you exactly how much, but it's not very much money because we attempt to collect most of our debts ourselves. And we never garnish directly. Like we, as a part of our reasonable process of collections, attempt to collect the debt for probably six months to a year, and then we turn debt over to a collection agency because it becomes more effective for them to continue. And then they ask us for permission to take cases to court, and that does not happen very often. But I don't have exact numbers.
Representative Hamrick?
Thank you, Madam Chair. This is for the people from the debt collection agency. I'm wondering if you're part of a national company and if you have any satellites in Texas, Delaware, or Rhode Island. Mr. Shoup. Thank you for your question. We are a Colorado-based agency. We are licensed to collect in 49 states, probably about 40% of our activity is in Colorado. And we collect on, we do our litigation in Colorado in-house. Now we do have a partnership with a Texas law firm, litigation collection firm, that we outsource our accounts that warrant legal activity. And I'm not sure of the exact tools that they use.
Vice Chair Leader. Sorry. We have one more answer. For permission.
Mr. Betcher. Thank you. Yes, so we do collect in Texas. In Colorado, we see that about 50% of our total collections in Texas, we see about 50% of what we collect in Colorado. And again, that is because, again, garnishment is an absolute last case resort. It's never anything we want to do. Legal action isn't what we want to do. However, in the absence of that, there are Colorado clients that I have that have made the decision, hey, we do not want to pursue litigation anymore. Not only do they lose all of their legal collections, we see that about 30 or 40 percent of their non-legal collections also go away as an impact.
Representative Hamrick. Thank you, Madam Chair. And what tools do you use in Texas to collect?
Phone calls, text messages, and emails, and goodwill. And then what assets do you go after in Texas? Mr. Richard. I apologize. No problem. So we actually do not pursue any litigation in Texas because it would not be cost effective. A big piece of litigation is we pay those costs up front, and we would never pay that cost if we didn't think there was a return on that investment. Again, that's the ability to pay of the patient. And in Texas, without the garnishment, there is very little return on investment of those funds.
Vice Chair Lear. Thank you, Madam Chair. we'll just go ahead and pick on Blake this question is for you so I'm curious how do you deal with the collections when the person you're contacting to say that they owe collections to BC Services how do you deal with it when they tell you that they were built incorrectly by the hospital they say that for instance they have like myself very blessed to have a primary and a secondary insurance and for whatever reason they just cannot get it right with that secondary insurance. They do not bill that secondary insurance. And I spend hours, countless hours on the phone trying to go back and say, hey, did you bill the secondary insurance? But no, they've got BC Collections calling me or a family member telling me, oh, hey, you owe this XYZ. And I don't know how many times I've already spent on the phone with the hospital, and now I'm spending it with you. So how do you handle that when the person you're trying to collect from tells you they were billed incorrectly?
Mr. Batchett. Thank you, Madam Chair. Thank you for the question. Again, I don't want to collect any money from somebody that doesn't actually owe it. If that is a dispute that they have, we always ask them, hey, send it over to us in writing. It goes over to our compliance department. Not in writing. Email's fine, too. Just to get the millennial. I apologize. But we ask them to send that in to us because as soon as we have that, then we open up a formal investigation. That account then goes on hold. We then give that information back to the provider, however that may be. Usually we're able to see if it's in the system and if it was billed, if it was denied, why not? And then that's where we put on our problem solver hat and say, hey, it looks like they tried to bill secondary first. That's why it denied. That's why your primary denied. we work very closely with all of our provider clients to try to straighten those situations out. Unfortunately, as a third-party collection agency, the insurance companies won't speak to us, so we are truly reliant on the patients communicating with us to facilitate the resolution of that account. Thank you.
Thank you for that. In this case, they just don't even bother to build a secondary. But my next question is for I believe Scott Kenyon Okay so you said that if this passed that you would be forced to have people pay up front So I heard you mention contracts So do you not enter into a contract with an insurance company as an in-network provider? Because my insurance company always allows them, they tell them part of my contract that they will bill the insurance first, and then they will bill me what I owe after the insurance has been billed. So by your own accord of saying that, would you not be in breach of contract with the insurance companies for the in-network provider services?
Mr. Ken. Thank you, Madam Chair. Yes, Representative Leiter, that is an excellent question. Sorry, Leiter. There are a lot of technology advancements today that allow us to do what they call pre-claim resolution, where you can create an estimate using the computer system to speak directly to the various payers and estimate what you think the bill is going to be in terms of patient responsibility. And we could use that information to ask for payment up front, which would not violate our contracts with the payers because the payers are aware since they're ultimately providing that info to do the claims adjudication estimates in advance.
Okay. Oh, quick follow-up. We're past. Okay, sorry. No, go ahead. Okay, well, in my mind, my insurance company tells me then I get to wait. So to me, you would still be in breach of that contract because of what I have. What I'm paying for my insurance is they tell me to pay for it afterwards. So to me, that would still be in a violation of it, even though I know what you're saying. And then by what I just told Raycare, it's not always accurate, and then we're going to be back to square one when they're not billing me accurately, but you're forcing me to pay up front. But that's all. Thank you. Okay. The time has passed, but we'll do one quick question from Representative Johnson.
Thank you, Madam Chair. Question on why you're not, as a third-party collector, not allowed to talk to insurance. And then the second part is, can you talk to hospitals when you're trying to figure all this out, or is all a burden on the patient?
Mr. Boettcher. Thank you, Madam Chair. Yes, we are not able to because of HIPAA laws, and most of the time because they don't want to talk to us, unfortunately, like most of the patients we try to contact. And so they will not communicate directly with us unless the patient is on the phone, and we oftentimes do ask for a three-way call. I have had collectors hold for an hour for insurance to then try to resolve that account so yes they they do not as far as hospitals we are contracted and so yes we do have full communication with them about the billing and and any proceedings that we do and collection activity on their accounts. Okay thank you so much the time has passed for this panel we
appreciate your participation. We will now move into our amend folks. Let me call up John Vargo, Yossi Jansen, Michelle Marin, Matt Kelly, and Isabel Henshaw. And then I think we have Doug Farmer remotely. And we might have one additional person, so if you all don't mind just pulling an extra chair up, I would appreciate it. Great. Thank you all so much for joining us today. We switch it up We start from my right to my left If you could introduce yourself The organization you represent you have two minutes Thank you Chair Gilchrist I Matt Kelly Senior Director of
Patient Financial Experience for UC Health. I'm testifying today in an amend position on House Bill 1267. Our top priority is to serve all patients and keep people healthy. As Colorado's largest Medicaid provider, UCHealth is committed to ensuring patients can access care regardless of their ability to pay. In my role, I help design the processes patients use to apply for financial assistance and to set up payment plans they choose and can afford, including zero interest monthly plans. Most patients create their own plans online. They choose payments as low as $25 per month with terms up to 42 months. We also provide automatic self-pay discounts and access to financial counselors. Importantly our initiatives have long helped hardworking people and are more generous than Colorado's minimum hospital discounted care requirements. We've heard about billing challenges today and we empathize. Over the past year we've listened and we've taken comprehensive steps to provide financial assistance for patients who need it. As a result, participation has increased by 40% since 2024. Healthcare providers are able to offer flexibility and sensible discounts because we rely on everyone to pay what they can. This is even more important as we see more patients with high deductibles. We also maintain strong safeguards to ensure that no one is referred to collections inappropriately. We've dramatically reduced court filings and now avoid this more than 99.98% of the time. We are on track to reduce medical debt lawsuits by two-thirds compared to 2024. As introduced, this bill would allow wealthier patients to avoid or ignore paying their bills. That would raise the cost of care for everyone else and limit our ability to help those who truly need financial aid. I understand there are amendments that will be offered today. Unfortunately, however, more changes are needed to protect low-income patients while ensuring those with the means to pay must do so. Thank you.
Thank you. Please proceed. It's right by the plug. Good afternoon, or good evening.
Thank you, Madam Chair and committee members, for allowing me to testify today. My name is Michelle Marone, and I'm an attorney with the law firm of Stokes & Wolfe here in Denver. It is a small creditor rights firm, and we serve only debts for Colorado creditors. We ask you today to oppose. Actually, we are in an opposed position, not an amend since I registered to this House Bill 26-12-27. I am here to talk about the fiscal impact. I think your legislative staff reported that the fiscal impact of this bill would be zero, which is simply not true. As to the fiscal impact of this bill, one concrete example is the elimination of filing fees associated with writs of garnishment. due to this bill's proposal to prohibit garnishment from medical debt altogether. Per the proponent's own published information, they have said between 2022 and 2024, Colorado courts approved approximately 14,000 wage garnishments each year for unpaid medical bills. That represents a budgetary hit to the state judiciary of approximately $630,000 annually, 14,000 writs at $45 per writ filed. Also the proponents have said at this hearing that there was approximately 24 medical debts filed At a minimum a filing fee is charged to each case that is filed That is a $2.3 million hit to the state judiciary system. As background, currently Colorado's state budgetary general fund shortfall is predicted to be nearly $1.5 billion for the next fiscal year. That gap is significant and urgently needs to be addressed. Taken together, the fiscal impact extends well beyond the cost of the filing fees just for writs of garnishment. It also concerns the complaints filed as well. It can include substantial reductions in that revenue. So we ask you today to urgently, we urgently request you to say no to this House bill. Thank you.
Thank you. Ms. Hinshaw, please proceed.
Thank you, Madam Chair and members of the committee. My name is Isabel Hinshaw. I am the Director of Policy and Government Relations for the Colorado Academy of Family Physicians. I am speaking today on behalf of CAFP's President, Dr. Corey Lyon, in support of the amended version of HB 26-1267. First, I would like to express our sincere appreciation to the sponsors and stakeholders for their willingness to engage in thoughtful and collaborative conversations. CEFP had concerns with the bill as originally introduced, particularly regarding its potential impact on small and independent practices. We believe those concerns are addressed in the amendment being brought forward today. We are grateful for the meaningful compromises reflected in the amendment. The amendment being brought forward today ensures that bad actors engaging in predatory medical debt collection practices are held accountable, while also avoiding unintended consequences that could place administrative and financial burdens on small practices. This legislation advanced an important shared goal of protecting patients. No Coloradans should fear losing their primary home or having their wages garnished for seeking care. Financial barriers and fear of debt can have real consequences on health outcomes, and this bill takes a thoughtful step towards addressing those concerns. Family physicians are deeply committed to both the health and well-being of our patients and the sustainability of practices that serve them. We believe the amended bill reflects a great balance. For these reasons, CAFP is pleased to support the amended version of 1267. Thank you for your time and consideration.
Thank you for your testimony. Please proceed.
Good evening. My name is Yossi Jansen. I am a practicing Colorado debt collection attorney. I'm also a founding member of the Colorado Creditor Bar Association. When I signed up yesterday, I was in an amend position. Unfortunately, I've had to change my position to oppose. I'm going to discuss the shortening of the statute of limitations within this bill. Most of you probably know this, but the statute of limitations is the amount of time someone has to sue another. For debt collection, it's usually six years. The shortening of the statute of limitations from six to three years will have some pretty tough consequences. Most non-profit and tax exempt hospitals, all the big ones that you've been hearing about today, they are required to comply with a federal tax code requirement, which would actually shorten the three-year proposed statute of limitations even more to just a little bit more than two years. And these nonprofit and tax-exempt hospitals have to provide consumers a 270-day kind of a grace period to help them find ways to pay this bill, to find charity, help with insurance. any kind of financial assistance. So really this three-year period is getting even shorter to a two-plus few months time period. Patients with medical debt typically have a reduced income during their medical crisis. Now we've got the Colorado Family Medical Leave Insurance Program, but that only pays the average Coloradans 70% of their wages, making it unreasonable to expect that any consumer or patient would be able to pay their medical debt during this reduced period of time. Further, for patients that are still recovering from their ailments, this is just going to add more pressure to them. They're going to be focusing on the fact that debt collectors are calling during this two-year period and even maybe filing suit. so it's just not going to help consumers by shortening the statute of limitations
does that mean I'm up? yes, thank you so much for your testimony we appreciate it and if you don't mind, can you just pull the microphone closer thank you so much I think you might have turned it off there you go is there a countdown button to hit? no, someone hit it
hi everyone My name is John Vargo. I'm here representing Colorado Credit Bar Association. I'm not an attorney, but I work for a collection law firm. And I also am changing my stance from amend to oppose. The problem I have with this bill is its elimination of liens against property. First of all, liens against property does not mean that the house is going to be lost. It doesn't mean foreclosure. Colorado law already prohibits foreclosure on medical debt. And even if it didn't, it's very rare to do a foreclosure on a judicial lien. It only happens if the lien is high enough. You're talking $20,000, $30,000, $40,000 plus. Plus there's equity involved, homestead exemptions that protect the consumers. There's a lot of protections against losing a home for debt in general for foreclosure. But liens are very important in the collection process, especially against people who have the ability to pay but do not want to because liens will remain on cloud the title of their house and it precludes them free financing or selling their house, especially at a profit and not paying off debts that they have been trying to avoid for many, many, many years. So I oppose this bill and I urge you to vote no.
Thank you so much for your testimony.
we'll move online to Doug Farmer. Thank you, Madam Chair and members of the committee. My name is Doug Farmer. I'm president of the Colorado Healthcare Association. We represent nursing home and assisted living providers throughout the state of Colorado. I'm here to express my concerns about 1267. We certainly support ethical debt collection practices, but the bill contains three areas of concern for our providers. First is a 30-day advance notice prior to in-house collection activity. We have regular ongoing dialogue with our residents regarding their financial responsibilities, and this would limit our ability to do that. Second is prohibiting collection activity against anyone who is not the patient. Our setting is unique in this conversation in that all of our residents sign contracts, resident agreements prior to admission, and those agreements include financial requirements costs of care to be provided and timing of payments and responsibility for payments so not surprise billing Further many long care residents are unable to manage their own finances so family members often co-sign a contract, and sometimes a family member is the sole source of payment for services and is the reason that the person is able to live in a senior care setting. The last is prohibitions regarding liens. A critical component of the Medicaid program is that clients have financial responsibilities for the cost of their care known as patient payments. A Medicaid client by definition can't have more than $2,000 in assets, which means we've been able to enforce collection of their patient payment. We already have challenges when a patient's family member has taken what little money they have, and this bill would make pursuing those family members nearly impossible for us. The inability to collect payment for our services would destabilize the long-term care sector, excuse me, and could lead to restricted access I ask that you do not pass 1267 without significant amendment.
And I thank you for your time. Thank you for your testimony. Any questions from the committee? Okay. Oh, sorry.
Representative Wright. Thank you, Madam Chair.
The question is for a UC Health person. I'm sorry, I forgot your name. Can you kind of help me understand how much you've captured or how much UC Health, let's say, in the last four years has captured in liens and waitings? and garnishment and how that relates to the overall operating budget of the hospital.
Mr. Kelly. Thank you, Madam Chair. Thank you. Oh, I don't think you're – there you go. Thank you, Madam Chair. Thank you, Representative. I don't have those exact figures, but it does represent a very small percentage of our overall population. Legal is a method of last resort. And as I stated in my testimony, 99.98% of accounts are settled without the need for legal intervention. And so it represents a very small percentage of our overall patient population.
Like 0.01, 0.001? Like what are we talking ballpark?
In terms of accounts that go to legal activity, out of the full pie of our 8.7 million accounts, it's only 0.02%.
Representative Hamrick. Thank you, Madam Chair. This is for the Colorado Family Physicians representative. And you mentioned how you really like the amended version because it sort of tames bad actors. Can you elaborate a little bit more on that?
Ms. Henshaw. Thank you, Madam Chair. Thank you, Rep Hamrick. I'm happy to. We had many conversations with our members, including members that have small practices that had concerns with the original language and the challenges that could be faced with the potential fines for administrative challenges and things like that. Changing the bill as amended, it's now only having to do with these extreme actions. This fine only applies in cases where a primary home would be faced in these cases or wage garnishment. And we believe that those are appropriate protections to have. As our patients, we want to ensure that they have access to stable housing, access to food and some form of income. So we believe that focusing on those aspects are appropriate.
Representative Redd. Thank you, Madam Chair. A follow-up question again. I'm referencing a Colorado Sun article that addresses a little bit of this issue. So it says UC Health filed more than 15,000 lawsuits.
Can you tell me of that how many actually went to wage garnishment and liens and the things we talking about specifically today and what going to be amended Mr Kelly Thank you Madam Chair and Thank you Representative for the follow question I think that in reference to an article that was using some older data, but looking at our most recent last year in 2024, only 5% of all accounts that went into legal resulted in garnishment. The vast majority are settled or we set up payment plan arrangements prior to it needing to get to that point.
Any additional questions from the committee? Okay. Seeing none, thank you so much for your testimony. We appreciate it. We will move on to our next support panel. Let's call up Lisa Busig, Jackie Penfold, Diana Leyva, Jess Broadbent. And then I'll try some folks online as well. Can we do Matt Guerrero, Sandra Lamb, Jade Kelly? Any of those folks online? Okay. She's not here, but she might be able to call her. Okay. We can call her again later. Sarif Toy. No? Oh, yeah. Oh, okay, great. Perfect. I will start from my left to my right. If you could introduce yourself, the organization you represent, and you have two minutes. Yes, my name is Jessica Broadbent. I'm a member of the Colorado Care Workers United. I'm also a mental health worker, a nursing student, and a member of the community. I'm here today to urge a yes vote on this bill. Twelve years ago, I actually filed bankruptcy because of medical debt. I was approximately about $50,000 in debt of bills that I could never pay. I was uninsured, and I did what I had to do to support my family. and kind of paid what I could, and then it just got to a point of absolute overwhelm. So I, and that alone delayed my ability to purchase a house because I was a renter. And we mentioned a lot about protections for folks protecting their homes. What about the renters? I currently do own a home here in Colorado, and that has come at a great cost to me. so I literally just had surgery last year that I am constantly trying to figure out how to pay not only just one ambulance bill but a hospital bill and trying to not only do that but for myself, my child who is under the age and then also my husband because Colorado holds me financially responsible for my husband's bills as well and BC Services is actually already calling me and I'm having to go back and forth with them So I 100% dispute their non-predatory reactions. After a hysterectomy a few years ago, I was home and I collapsed with septic shock. And the first thing that I thought when I woke up, I can't afford this. I'm going to go bankrupt again. I spent nine days in the hospital with no income and with a massive bill. Thankfully I was able to take care of it and I feel like in my experience with BC Services they would have rather me just stayed home and died because I didn check my bank account prior to make sure that I could financially afford this medical catastrophe of which I did not plan I work hard for the credit that has afforded me my home, my employment, my life, and to have an unplanned medical bill derail my effort is absolutely unfair. Thank you so much for your time. I really appreciate it. Please proceed. Where's the button? It's that tiny little, got it? Okay. Thank you, Madam Chair and the members of the committee. My name is Jackie Penfold and I'm a licensed clinical social worker living in Loveland, Colorado. Although retired, I remain active in the National Association of Social Workers and I am the representative for the Northern Region of the NASW Colorado chapter. I also understand there are legislators on this committee who are also social workers bound by the same code of ethics that brings me here today in support of HB 1267. This bill particularly struck me because of medical debt experiences that I've had personally and professionally working as a medical social worker. On a personal level, my son was born with a congenital heart defect and needed open heart surgery. As parents, we did everything needed for him to recover and go on to live a healthy life. Unfortunately, insurance refused to pay, and we were left with bills that forced us to file for bankruptcy. During this same time period, I was diagnosed with multiple sclerosis. Because we filed for bankruptcy, it took us decades to rebuild our credit to where we were again able to purchase a home and a dependable car. My health care is extensive and expensive. Just one of my medications is $10,000 each month, and I have a variety of specialists for my MS. I spent hours checking my bills to protect myself from falling into collections in fear that I could lose my home or my retirement. Professionally, I was on a team that provided services to those with developmental disabilities and later worked for the VA on teams at the medical clinic. Unfortunately, there were often times when provided care was not covered through Medicaid or the VA and there were threats of legal action. The angst felt by those impacted by medical debt is palpable. After working for health care systems throughout my career, I understand the need to keep the doors open and pay staff, but these practices are not that. Collection actions by corporate-run medical systems are beyond ethical business practices. I cannot emphasize strongly enough the need for you to vote yes on HB 1267. Thank you for listening to my reasoning of why passage of this bill is vital, not only for me but for all of the residents of Colorado. Thank you so much for your testimony. Please proceed. Thank you, Madam Chair and members of the committee. My name is Lisa, and I'm here today as a member of Colorado Care Workers Unite, urging you to vote yes on HB 1267. As a home health care worker, I dedicated my time to healing people who are sick or near the end of their lives. While this is an important part of my life, I'm here because I myself have severed from medical debt and collection practices. When I first moved to Colorado with my family, my son was in two car accidents back-to-back. One was covered by the other person's insurance. The other one was not. At that time, my household did not qualify for Medicaid coverage, so we were left with no way to pay those bills. I want to mention also that these bills were double billed and I was also receiving collection notices from both of the agencies that were represented here just a minute ago we were sent to the collections um In the beginning of my medical debt story in Colorado, it was actually a single antibiotic shot that my nearly 18-year-old son needed later that put our family on the edge. This one shot cost over $800. I was told by 211 where to go, and that's where I went. And they were $800 for an antibiotic shot. we were sent to the collections before we could even get our hands on an itemized bill or a payment plan the debt collector started coming after me my daughter, she was trying to buy a house and she couldn't because of this and when my son turned 18 they went after him it was extremely stressful and scary and I had to miss work I had to borrow money to pay for a mediator and I was threatened with jail You know, those kind of collection actions are discriminatory and humiliating. So when I needed help, I quickly learned that if you're poor and need health care, you're just going to get poorer. The nature of my work can be unstable. I've worked jobs where I haven't been paid, leading to homelessness. When my hospice patients would die... You can go ahead and finish your sentence. I can go periods of time without work. As a self-employed home care worker, I would never afford home care for myself. I don't have any retirement, no employer-sponsored insurance, no huge savings. I should have the basic right to seek out health care without worrying I'll end up in severe debt. The protections of this bill gives me peace of mind that I won't lose everything and give people a chance to afford the care without ending up in court. Thank you. And I ask for a yes vote. Thank you for your testimony. Please proceed. Thank you. Good afternoon, members of the committee. Thank you for the opportunity to speak today. My name is Diana Leyva. I am an Aurora constituent. I'm also a public health professional, and I'm here representing myself. I respectfully urge you to vote yes on House Bill 26-1267. When I was 20 years old, I went to the emergency room for severe stomach pain. At the time, I was uninsured and living in Florida without access to Medicaid. I was a college student working two part-time jobs, living five hours from home, and at times living in my car in between semesters just to stay employed. After several hours in the ER, I was discharged with no diagnosis. A few weeks later, I received a $3,000 medical bill. At this point in my life, I barely had money in my bank account. Even small expenses could trigger overdraft fees. A payment plan was not feasible, and the nonprofit hospital refused to dismiss my bill. Ultimately, it was sent to collections. My credit score dropped, making it even harder to secure stable housing. That experience didn't just affect me financially. It changed my behavior. The fear of taking on more medical debt kept me from seeking care. For the next four years, I lived with an undiagnosed chronic condition in constant pain, avoiding doctors because I couldn't afford another bill. I eventually dropped out of college, delaying my ability to improve my financial situation. Medical debt doesn't just impact people in the moment. It creates long-term barriers to health, stability, and economic mobility. This debt is now behind me, and while I was fortunate to avoid weight garnishment or losing my car, uh, sorry, the stress and consequences were still significant. I can't imagine what wage garnishment would have meant and where I would be today. I likely wouldn't have gone back to college or bought my first home. The protections offered in this bill are critical in preventing Coloradans from slipping further into poverty. We can't fix everything about our healthcare system overnight, but we can stop people from being pushed further into poverty just because they got sick. This is about dignity It about fairness It about whether we believe people deserve a chance to get back on their feet after a medical emergency For these reasons I urge you to vote yes on House Bill 26 Thank you for your time Thank you You did very well Moving on to our online folks, Matt Guerriero. Thank you, Madam Chair and members of the committee. My name is Matt Guerriero. I'm a pediatrician in Denver, and I'm representing myself. I urge you to vote yes on 1267. I'm a physician at a private practice with a panel of about 9,000 patients. And I'm currently in negotiations to take over the practice as a sole owner, so I'm acutely aware of the revenue needs of our clinic. Every dollar we earn is essential to staying afloat. And yet, my practice does not send any families to collections or use any extraordinary collections practices. Primary care pediatrics is not a high revenue generating field. Because our clinic does not screen patients by insurance type and also cares for uninsured patients, we experience even lower rates of reimbursement. And nevertheless, we are financially stable and growing. Practices like mine are proof that providers can care for patients without relying on extraordinary collections actions to get paid. My clinic has made the intentional decision not to send families to collections because participating in a system that risks financial ruin for our patients is not aligned with our values. On top of that, realistically, the revenue that returns to the practice is negligible. It's just not worth the harm to patients. Opponents of this bill have argued that it would put hospitals and clinics out of business, that it would lead patients to simply stop paying their bills. However, no evidence to support these claims has been presented. Other states with similar protections have not seen this play out, and neither has our practice. Our patients value the care they receive, and they pay their bills. It's that simple. Being a pediatrician is the best job in the world, but the barriers that prevent families from accessing care are profoundly frustrating. Fear of medical debt and its consequences is one of the main reasons that people delay or avoid care, as we have heard. I've seen this firsthand, too. One of my most beloved families lost their father to COVID-19 because he waited too long to get help for fear of the financial burden on his family. I am here today because I do not want to participate in a system that destroys people's lives or forces them to make impossible choices that end in tragedy. If a small independent practice like mine can refuse to pursue extreme collections actions, a larger health system with much deeper financial buffers can as well. Please vote yes on House Bill 26-1267. Thank you. Thank you so much for your testimony. We'll move on to Sarif Toy. Thank you very much. Good evening. Thank you to the chair and the members of the committee. My name is Sheriff Toy, and I'm an emergency medical technician and working as a critical care technician in a rural emergency department in Colorado. I'm also a member of Center for Health Progress, and I'm here in support of this bill. I want to address the concern that this bill may harm rural hospitals. From my experience on the ground, I see the opposite. I want to address that rural hospitals are often the only safety net in their communities, and I think they depend on trust. When patients fear aggressive collection practices like wage garnishment or facing lawsuits, that trust is ultimately damaged. And this bill does not prevent hospitals from collecting payments. It creates a more structured and fair process that takes into account the patient's ability to pay while still allowing hospitals to be reimbursed. What it does prevent are practices that can push patients into deeper hardships. I seen many patients who are already struggling to choose between paying medical bills and paying for basic necessities their housing their electricity bills or their food When patients are placed at risk of losing wages or falling behind paying their bills, they're more likely to delay their routine care and they will skip their primary care appointments or they will ignore their early symptoms, which will ultimately cause them to come in and their conditions to become more emergent. And this leads to worse outcomes for patients and higher costs, not only for the patients, but also health care systems as well. Emergency departments become the default point of care, and often the conditions that could have been prevented and managed earlier becomes too late and financially burdened. When the patients already are in debt collections and their wage is garnished, we also have to ask ourselves, what will happen if the same patient shows up in the emergency room? Who's going to pay their next bill? And protecting patients from aggressive collection practices is not just a financial issue. It's a public health issue, and it supports earlier care and preserves trust in the system and ultimately benefits both patients and hospitals. Thank you very much. Thank you so much for your testimony. We'll move on to Michael. Thank you, Madam Chair Gorkrist and members of House Health and Health Men Services. My name is Michael Neal. I am a member of the year for Colorado People's Alliance, and I'm testifying in strong, strong support of this bill on their behalf on my own. I grew up using private insurance until about age 11 and then was able to get into a waivered service for Medicaid and then eventually on to Medicare. I have been incredibly lucky. One would think that 18 surgeries would have been an immediate recipe for medical debt. And they'd probably be right if it were only if people were not insured or were insured only catastrophically because we had decent insurance, even though we were still relatively poor when I was young. I did not end up in this situation, but I can sort of only imagine what it would be like to be a person in my similar circumstances of having 18 surgeries for my disability throughout my life, but not having those particular safeguards of insurance. And so I can easily imagine myself as having the potential for this mass medical debt. That is also true of a lot of COPA members who live on margins of our economy. And so for them and for folks that are really on these margins, I ask for an aye vote on this bill. I do wish that it were a stronger bill more closely related to its original version. But I know how this dome works and how we have to compromise So we pass what we pass and I urge an aye vote hoping that we can get back to better and more things later Thank you so much for your testimony. Questions from the committee? Representative Wright. Thank you, Madam Chair. Thank you. I think I received some of your written feedback as well, I think from you and possibly from you. So thank you for that. That was really helpful. My question actually is for you on the end. Tell me why the payment plan wasn't feasible. I was broke. I had no money, so I couldn't pay. Also, like I said, I was a college student, so I barely had money in my bank account as it was. And thankfully, you know, I lived in Florida, and Florida didn't garnish my wages or take away my little property that I had, which was my car. So, yeah. Okay, thank you. Additional questions from the committee? Okay, seeing none, thank you so much for your testimony. We really appreciate you participating today. Okay, we'll move back to our opposed panels. Let's bring up Bridget Frazier, Kelly Herb Zager, Josh Hannes. And then Adam Conley, who's virtual. Julia Jansen. Teresa Wagenman. Jen Riley. And Ron Hogan. Okay. With that, we'll start in person. I will start from my left to my right. If you could introduce yourself, your organization, and you have two minutes. Great. Thank you, Madam Chair and committee members. Thank you for the opportunity to speak this evening. My name is Kelly Herb Zager with the Colorado Rural Health Center. CRHC supports the hospitals and clinics in Colorado's rural and frontier counties. I'm here today speaking in respectful opposition to House Bill 1267. I want to start by saying that we know folks may struggle to afford health care services because they are the friends, families, and neighbors of our rural health care providers. The struggle to survive is felt across rural communities, and despite these frightening realities, rural Colorado hospitals have been determined to support patients navigating health care costs. Rural hospitals assist patients with medical bills primarily through financial assistance programs like the hospital discounted care program, screening for public insurance, and offering flexible payment options. and many times they provide care knowing they won't get paid. A hospital on the eastern plains shared that on many occasions they have resisted discharging a patient despite direction from a patient's insurance carrier, even when the hospital knows they will not be reimbursed for the care. Rural hospitals have dogged persistence with insurance companies, working relentlessly on behalf of their patients to chase down prior auths, navigate claim submissions and appeals, and justify continued hospital stays. They do it because it's in the best clinical interest of the patient and the right thing to do for their neighbors. But the inability of a rural hospital to collect payment for services rendered will lead to staff reductions that impact the economic viability of a rural community and service reductions or even closures that decimate rural access to care. Twenty of Colorado's 43 rural hospitals are operating with negative profit margins, and the median profit margin for all rural hospitals is negative 0.4%. At the same time, Colorado's rural hospitals are bracing for the impacts of HR1, which is expected to increase rural Colorado uninsured rate to over $100,000 and increase uncompensated care to over $230 million. I welcome continued negotiations with the bill's sponsors, but right now the bill is unworkable for rural health care providers, so I respectfully urge your no vote. Thank you for your time this evening. I'm happy to answer any questions. Thank you for your testimony. Please proceed. Good evening, Madam Chair and members of the committee. My name is Bridget Frazier, and I represent the Colorado Hospital Association. We share the goal of ensuring patients can access care without the stress of medical debt. We are deeply committed to being a part of the solution at a time when cost pressures facing the entire ecosystem of care continue to intensify. We have offered several potential solutions to the bill proponents and sponsors, but despite our collaborative efforts, we were unable to identify a feasible path forward. That is why I am here today in opposition to House Bill 26-1267. Colorado already has some of the strongest medical debt protections in the country. Before any collection activity can occur, hospitals must wait at least 182 days, provide clear written notice, and fully screen patients for financial assistance. If a patient applies for financial assistance, collections must stop. If they qualify at any point, hospitals must reverse collection actions and refund payments. Medical debt is not reported to credit bureaus and interest rates are capped. These are meaningful and forcible protections that ensure patients are given every opportunity to access financial assistance before any collection activity occurs. In addition, hospitals comply with hospital discounted care requirements, which expand access to free and reduced cost care for low- and middle-income Coloradans paid for by hospitals. These patients are also entitled to payment plans, and their bills are considered paid in full after 36 months. Medical care is not free to deliver. Every dollar recovered by a hospital is the funding behind a life-saving piece of equipment, a rural emergency department that may be the only one for miles, and the highly skilled health care workforce that patients depend on when they need it most. When hospitals are unable to recover costs, those costs have to be spread across the health care system, ultimately affecting affordability for all patients. The concern with this bill is not its intent, it's the collective impact. By further restricting even permissible collections actions and creating significant penalties for technical noncompliance, the bill risks shifting the balance too far. Thank you for your time and thoughtful consideration. Thank you. Please proceed. Thank you, Madam Chair and members of the committee. My name is Josh Hannes, and I'm the Vice President of Rural Policy and Strategy at the Colorado Hospital Association. You heard from my colleague that we share the goal of protecting patients from financial harm, and in small communities, this issue is personal. These are our neighbors, and these communities are where we draw our employees from and where we send them home to heal. So it's critical for us that we're protecting everyone, but we do have concerns with this legislation. You heard earlier about the lack of sustainable margins in our rural hospitals. More than 80% have an unsustainable margin, and many operate at a loss, and we can't shift those costs as easily. Since 2024, charity and uncompensated care have increased by $56 million, a 17% increase. Compared to 2021, these costs have grown by $208,112,000,000, a $112,000 increase. Further restricting collections without addressing the underlying drivers of medical debt, like high deductibles and insurance gaps, does not eliminate the cost. It just distributes it in a way that is destabilizing the rural hospitals. So we believe there's a better way to achieve this shared goal of addressing medical debt. Insurance provider policies and practices are significant contributing factors to the affordability of care So we suggest going further upstream So for example high deductible plans and cost requirements In these plans, patients are responsible for thousands of dollars out of pocket and up front before insurance covers anything. These patients are effectively self-pay patients, despite the fact of having quote-unquote insurance. Number two, what we'd call low, slow, and no payment. Prior authorization requirements and claims denials frequently prevent payment for medically necessary care. I think you heard some stories about that earlier. Patients may be responsible for bills when carriers retrospectively deny coverage and after care has been delivered. Appeals processes are complex and slow, which shifts the financial burden back to patients. And number three, complexity and lack of transparency. Explanation of benefits are confusing and can lead to misunderstanding about what is owed by the patient and what is covered. And finally, rural hospitals are deeply committed to our patients. We provide care regardless of ability to pay, absorb significant uncompensated care every year, but we cannot sustain in a system where the costs are real, care is delivered, and then payment becomes increasingly uncertain. If rural hospitals are not financially stable, access to care disappears. We urge the committee to carefully consider the cumulative impact of this legislation and work with stakeholders to ensure that patient protections do not come at the expense of rural access. I appreciate your time, and I'm happy to answer any questions. Thank you so much for your testimony. We will move to the folks online. Could we could Julia Jansen come off mute and introduce yourself? Good afternoon, chair and members of the committee. My name is Julia Jansen, and I serve as the financial assistance supervisor at Gunnison Valley Health. And I'm here today to respectfully oppose House Bill 1267. Gunnison Valley Health is a lifeline for our community. We provide emergency care, primary care, behavioral health and long term care in a region where there are no alternative providers nearby. When someone experiences an emergency, especially in an isolated and remote area, we are the only option. We take our role in supporting patients very seriously. We proactively screen patients for Medicaid and other coverage, provide charity and discounted care, and work closely with our patients to set up reasonable payment plans. Our priority is always to help the patient avoid medical debt whenever possible. While well-intentioned, House Bill 1267 creates real challenges for rural hospitals. It adds rigid, one-size-fits-all requirements that significantly increase administrative burden, while further limiting our ability to collect payments for care that has already been delivered. Rural hospitals do not have large compliance teams or legal departments. Every new requirement pulls limited staff away from patient support and financial counseling. At the same time, tighter payment caps and longer timelines reduce already limited revenue. In rural health care, even small financial pressures have large consequences. Reduced or delayed revenue directly affects our ability to sustain essential services in our valley. Hospitals like ours are already doing this work this bill seeks to mandate. Adding more requirements does not improve patient protections. It diverts scarce resources away from patient care. In rural communities, when a hospital is strained, the entire community feels it. For these reasons, I respectfully urge you to oppose House Bill 1267. Thank you for the opportunity to testify. Thank you for your testimony. We'll move on to Teresa Wagaman. Great, thank you. Can you hear me? Yes, we can. Okay, thank you. My name is Teresa Wagaman. I am here representing Grand River Hospital District as the Chief Financial Officer We are a rural critical access hospital over on the western slope Again I appreciate thank you again for providing me this opportunity to speak before you today in opposition to House Bill 26-1267. This bill poses numerous unintended consequences and is an immediate threat to our ability to provide quality patient care. Specifically, I'd like to note that this bill does not differentiate between those patients who truly do not have the ability to pay and those who can pay and choose not to. And this distinction matters. When we don't distinguish between patients who truly cannot pay and those who have the ability to pay but choose not to, we lose fairness in the system and its credibility. The policies meant to protect vulnerable patients end up applying equally to those who are not vulnerable, and that financial responsibility doesn't go away. It's redistributed. Currently, we are required to provide patients with 30 days advance notice before sending an account to collections. That includes a clear explanation of their right to apply for financial assistance and hospital discounted care programs, along with clear instructions for how to apply. We already follow a lengthy process, which takes at least 182 days, as it was mentioned, before the account reaches the point of going to collections. This period includes insurance adjudication, financial assistance screening, and payment plan offers. If an error is made, we reverse any previous collection activity, and we refund amounts collected in excess of what is owed. By removing the key tools that enable us to receive payment for services provided, we're unable to collect from those patients who are able but unwilling to pay. Again, we make multiple direct attempts to contact patients, offer flexible payment plans, and screen patients for charity care eligibility. Every dollar counts in rural healthcare, and every dollar we recover goes directly back into the patient care, supporting staff, maintaining facilities, investing in new technology and equipment, replacing retired equipment, and ensuring that we can respond to emergencies in our community. When we are unable to recover those costs. The impact is real. This bill essentially ends our ability to collect on outstanding bills if patients simply choose not to pay. It shifts the costs. Again, thank you for the opportunity today. I urge you to vote no. Thank you so much for your testimony. We'll move on to Jennifer Riley. Good evening, Madam Chair and members of the committee. Thank you for the opportunity to testify today. My name is Jennifer Riley, and I serve as the CEO of Memorial Regional health in a small independent critical access hospital in rural northwest Colorado. I want to begin by saying this clearly. We understand that medical debt is a real burden for patients and families. We see it every day. In a community like ours, health care is personal. We know our patients, our neighbors, and their circumstances. That is why we go above and beyond to help. We provide financial assistance, we screen for Medicaid and other public programs, and we offer discounted care and payment plans. These are not just policies. They're part of our mission. However, I'm here today to express opposition to House Bill 26-1267. This bill, while well-intentioned, would significantly limit our ability to collect on medical debt after all reasonable efforts to work with patients have been exhausted. It adds additional notice requirements, mandates processes we are already doing, and creates substantial financial penalties, even for the unintentional missteps. The reality is that rural hospitals like ours operate on extremely thin margins. In just one year our bad debt expense increased from million to million That is care we already provided services delivered staff is paid supplies used but we were never reimbursed And this does not include the charity care that we willingly provide. When bad debt grows, it directly impacts our ability to sustain services. It affects staffing, access to care, and ultimately the viability of hospitals like ours that serve as a lifeline for our communities. We share the goal of protecting patients. While well-intentioned, this bill undermines hospitals and providers who are already striving to serve patients responsibly and effectively every day. I urge you to consider the unintended consequences this bill may have on rural health care access and sustainability. Your no vote would be greatly appreciated. Thank you for your time and consideration. Thank you so much for your testimony. We'll move on to Ron Hogan. Good evening. Thank you, Madam Chair and members of the committee. My name is Ron Hogan, and I have the privilege of serving as the CEO of Arkansas Valley Regional Medical Center in Lahanta. We're a critical access hospital. Within the last year, we've had to close our OB program, and we've had a reduction in force of 18 positions. My colleagues and I support the sponsor's goal of affordable and accessible care close to home. We do not want to leave patients in financial distress. We work closely and directly with patients every day in an attempt to prevent any amounts from going to collections, and as one of my colleagues said earlier, we live with the patients that come into our facilities so there are names that we recognize and faces that we know. Before any bill ever reaches collections, we undertake a multiple number of steps to connect with patients, including flexible payment plans, financial counseling, and screening for charity care. The past year, uncompensated care across the state has risen over 112%. In our small hospital alone, we had over $300,000 of true charity care within the last year and four times that much in bad debt. And by the way, we do not have our name stitched on the journeys of any professional teams, nor do any of my colleagues here that are CEOs of rural hospitals. The continual reference of the impact of UC Health and their practices is a little insulting for all the rural hospital administrators that are on this call and that have sat through this testimony for the last four hours. We do care. We should also be clear about the factors that contribute to the rising debt. We're part of a much larger system. Insurance plans in particular have a prevalence of high deductible payment plans and many of our patients are part of those plans. They come to us thinking that they have insurance and they have great care, but in fact, they're uninsured. That's not our fault. It's not their fault. While the intention of this bill is solid, the point and the focal aspect of it actually needs to be more towards the plans and less towards hospitals and their practices. It's a small, small, minute number of times that anyone actually sends a patient or has their wages garnished or sends them to collections, but it is a tool that we have to be able to use in our effort to get paid for the services that we provide. As mentioned several times over, every dollar we collect goes back into our institution, doesn't go for profits that are distributed out to owners, but simply goes back into pay for the services that are critical for these areas in which we live. And by the way, we're the only hospitals and 55 miles. If we don't survive economically, it won't really matter whether or not there's ways to be going. We won't have hospitals. Thank you so much for your testimony. We'll move on to Adam Conley. Good evening, Madam Chair and the members of the committee. My name is Adam Conley. I serve on the executive leadership team for Southwest Health Systems in Cortez as the chief financial officer. I thank you for the opportunity to speak to you in opposition to House Bill 26, 1267 this evening. Initially, I'd like to offer that this bill does not fully consider that all of the robust consumer protections that have gone into statute over the last several years, hospital best-counted care is an example that's been brought up several times. It also does not take into account that in the state of Colorado does not allow reporting of medical debt upon consumer credit, and so we are not able to use that as an avenue either. Additionally, this bill eliminates all the methods of recourse for Colorado's health care providers to recoup out same patient medical bills and does not differentiate between, again, those that are unable to pay due to extenuating circumstances and those that have the ability but are choosing not to. If enacted, this could spread the cost of unpaid medical bills across patients, other patients increasing the overall cost of health care and also increasing the cost of health care insurance in the state. Finally, this bill reduces the provider's ability to create flexible payment plans and options that really benefit the patient. Here, we have several patients who are on unique, very specialized, tailored payment plans and take pride in coming into the hospital to pay those medical debts. The lack of flexibility this could create could also penalize seasonal workers and gate-style workers, of which we have several who come through the area. These well-intended protections could really reduce our ability to tailor these solutions and provide what the patients ultimately need. Again, I thank you for the opportunity to oppose this bill and happy to answer any questions you may have. Thank you so much for your testimony. With that, we'll go to questions from the committee. Representative Stewart? Sorry. Thank you, Madam Chair. I'm trying to figure out how to phrase this. So my question is for Ms. Riley. Thank you so much for, I mean, I appreciate you all being here. you said you all have 6.8 million in bad debt so I'm curious how much are you able to recuperate from collections Ms. Ryan thank you I apologize thank you Representative Stewart for the question I don't have that specific number but it is a very small percentage that we recover through collections And if you don't mind, I'd like to expand a little bit on the threshold and the things that we do. We do not send people to court and garnish wages without a true belief that they have an ability to pay. We work with A1 Collection Services, which we are part owners of through Western Healthcare Alliance, and they have extremely ethical and participatory practices with our patients. We know our patients and we know their circumstances. And to Teresa Wegman's point, this bill is seeking to look at everybody the same. There are patients who have no ability to pay, and then there are patients who do have the ability to pay but refuse to do so. And that becomes very problematic for us as we're trying to work through who can pay and who we should try to collect those monies from. Representative Stewart. Thank you Madam Chair and I guess so follow up question and this would be for Mr. Connolly as I represent Southwest Memorial here at the Capitol and I am curious because in conversations with the sponsors like they're looking for concrete information around collections and what's necessary to help sustain rural hospitals so I mean and not just to Mr. Connolly if if others from CHA would like to weigh in or Ms. Zager. Can we talk about what, hold on, I lost my train of thought. Do you feel like this is death by a thousand paper cuts as far as we just taking one more tool out of the toolbox We staring down the barrel of H 1 and the implications of that We looking at a catastrophic budget year And I know I'm standing on a soapbox right now. I fully own that. Where provider rate cuts, I assume that we could be looking at that. So if you all could elaborate on where you feel this bill lands, what it's missing, and how you feel it's truly hurtful to rural hospitals, so I can have something solid, that would be wonderful. Mr. Connolly with Southwest Memorial. We've got Bridget Frazier here. We've got Josh. We've got Kelly. We've got Jen. Sorry. Who would like to answer that question? Mr. Hannett. Madam Chair, I'll try to take a stab at it. So Representative Stewart, I think what I would say is that, so yes, I think you're correct. It's removing yet another tool from the toolbox to collect on money owed in a constrained resource environment. But back to my original testimony, I think there is a larger and more impactful policy lever to pull here, which is the way that we regulate commercial health insurance. And when we have to employ and pay people that just manage that side of the business, these aren't people that are sitting at the patient bed. They're managing unnecessary, in our view, processes that many times end up in either us not getting paid at all for patients who have paid their premiums. They have coverage for covered services that care is delivered. We don't see that money. Or downcoding is a term where they pay us less for a negotiated rate on a particular service. Also, high deductible plans, as we talked about, are not at all insurance. People pay premiums, but they really don't have coverage, absent a catastrophic event. So I think there's something happening in this legislation that we have concerns about. But like I said, I would maybe ask everybody to consider the more impactful policy levers that could potentially stop, not stop, but mitigate the potential for medical debt on patients. Anyone else want to add to that? Okay. Oh, Ms. Frazier? I'm happy to add if you would like an additional response. So yes, I agree with and would echo my colleague Josh on potential solutions. This is kind of the perfect storm. We're in a terrible budget year. Our providers and facilities face cuts on the daily. Our rural hospitals and, quite frankly, hospitals across the state are really struggling to survive. So this kind of just adds to that perfect storm. and tanks the ship of another way to harm rather than provide good to our facility so they can continue to provide care. It also doesn't address the affordability argument in the context as well, and as Josh mentioned, there are policy solutions that can help patients receive care that is affordable and access to care. Representative Biden. Thank you, Madam Chair. I'm building on my colleague's question here, but for all the hospitals, specifically the rural hospitals, could you share with us how many cases you have filed and how much has resulted in liens and wage garnishment in the last, let's say in the last five years or whatever numbers you might have ready? I would like to answer that question. If folks want to online raise their hand or jump in. Mr. Hogan, it looks like you're off mute. I will. Yes over the last five years I believe it been slightly less than 10 maybe eight or nine and I think we collected somewhere around 20 to 30 Again the point is less about what we collected through the process but more about the fact that we can demonstrate that it is an opportunity or a tool that we can use or a tool on our tool chest as was said earlier If I could highlight one other quick distinguishing characteristic, especially about rural hospitals, You heard testimony from several of our colleagues that either served in medical practices or an elective only type service offerings. They don't deal with the Emergency Medical and Active Treatment and Active Labor Act like we all do as rural hospitals. Everyone that comes through our doors gets treated, gets treated with respect, gets treated fairly, and gets treated fully to the full extent of what is required under their medical condition. that oftentimes brings an increasingly higher number of bills that go unpaid, and we have to have an opportunity to collect those. Can we let Ms. Wigman? Yeah, I want Ms. Wigman, of course, to weigh in, but just for point of clarity, thank you, Madam Chair. Did you say 10 individuals over the last five years or 10,000? 10 or less individuals. I think it was eight or nine. Eight or nine. Ms. Wigman. I'll just add a few points and kind of to Ron's point. I don't have the dollars. I do have some percentage metrics of what we send to collections. Our collection rate recovery on that is about 20 percent. As far as wage garnishments goes, you know, it is a tool for the toolbox and it's not a lot of money. But again, every dollar counts. When we do utilize that mechanism, the success rate on that is about 70 to 75 percent when we when we use that mechanism. Amel Winter. Thank you, Madam Chair. Mr. Hogan, this question is for you. I think as we've gone throughout the day on numerous bills, I need you to paint a picture of how important your hospital is, how many counties and little communities you service in your area. I think that's what's lost in this as we're talking about money and you're talking about staying open. And I need you to paint the picture for everybody exactly what it means for you to stay open in your area. Yes, sir. Thank you. Just as a quick point of clarification, I was referencing patients sent that had wages garnished, not those sent to collections. The collections would be radically higher than that. So we serve a tri-county area as a primary service district, Otero, Benton, Crowley County, around a 23,000 to 25,000 population area. The next closest hospital to us is in Lamar, 51 miles away. Most patients that don't get service here end up going to Pueblo or Colorado Springs. We, as I said, we had to close our obstetric services a little bit over a year ago due to French constraints. We are a level four trauma, but we frequently get level three and level two traumas into our emergency room. We stabilize, we treat where we can. We do have four bed ICU capabilities here, but we oftentimes transport via air or ground up to Pueblo Springs. We are one of the largest employers in the tri-county area. We employ about 250 folks overall in terms of full-time equivalents, about 165. We see right at 1,100 patients per month in our emergency department, and we're not profitable. We're closer than we once were, but we're not profitable. We are a standalone not-for-profit organization. We not part of a larger UC Health or Intermountain Health or Common Spirit We do appreciate and enjoy strong working relationships with each one of those larger institutions but we just a small hospital that run by a local not board that's very, very strong and very positive in the way they support us, but we're crucial. We're crucial to the area. We're crucial to the citizens. We're crucial to the business environment, and most importantly, we're crucial to the healthcare delivery system here. We are simply the focal point. And the story I just gave you is repeated over and over and over across the state and, frankly, across the country. That's what rural health care brings to the table. And I'm afraid a lot of times decision makers really don't have any idea the impact that rural hospitals have on the community. Representative Frey. Thank you, Madam Chair, and thank you. It's been a couple of hours, and I finally am appreciative, Josh, that you brought up the different variables that might impact costs. And so things around controlling drug prices, prior auths, deductibles, denying coverage, provider networks, those are all things that we need to address. It feels like we're pointing the finger in the wrong direction in terms of why are these people in debt to begin with and go tackle that issue. But no one wants to take on the insurance companies in this building or in this world, it feels like. So I really appreciate that finally people are starting to come and testify and talk about the elephant in the room, which is the insurance companies that are causing these people to go into medical debt. So I encourage us to continue having that conversation in that direction rather than hunting down some of these people that are struggling to pay off that debt. So thank you for bringing that up, and maybe we can continue that conversation and lift it up. That wasn't a question. Do you think we should continue to have that conversation towards that direction? Mr. Hannes? Yes, ma'am. Absolutely. Love the Short response. Representative Johnson. Thank you, Madam Chair. And this is to anyone on the board. I know we have some hospitals, both private, both government, both urban, both rural, that have already set into place that you have to pay fully or 60% or some percentage before a patient can even book an appointment now. And I've heard some of my facilities, and I've reached out to others, that if something like this went in, that they might have to take up that model because if they can't find ways to get the payment from patients, they might put it on the front end. Is that something you all have heard? Because I'm scared, you know, if this bill would go through, what is the reaction? Because we're going to put hospitals out. How do we keep those hospitals in the state? How do we make sure we're not doing other things trying to keep these hospitals alive? Ms. Erbaker. Thank you, Madam Chair and Representative Johnson. I'll be honest, no. I mean, our members will not cap Medicaid patients. They will not cap Medicare patients. They continue to see their friends and neighbors. Now, it will come to the cost of their bottom line, which, as I said, currently right now, the median profit margin for a rural hospital is negative 0.4%. But I don't believe that they will put any sorts of barriers to access because that's not what their mission is in their communities. Representative Johnson. I guess a follow-up because there are, and we can talk offline, there are rural hospitals that have already put this cap in. and so I'm scared that others will follow suit because they won't be able to get the payment because of this bill, we'll be shutting off access in the hopes that we're not shutting off the lights. Amo Winter. Did we have a response? Is there a response to that statement? Ms. I'm so sorry. Thank you, Madam Chair, Representative Johnson. And I believe that that may have to be a tool in the toolbox for our hospitals that would reduce access to care in rural areas. Thank you. Sorry about that. AML Winter. Thank you, Madam Chair. Mr. Hogan, this question is. you because you do such a good job of painting a picture. We've talked about how critical you are to the area. Can you please explain to the folks in the room how you constantly have to do more with less and how you've been able to do that? Continue to provide this good service, but I really want people to hear how you have to do more with less and how you get it done so you're not paying it out to be this massive for-profit hospital that has these profit margins, And I just would like you to explain a little bit, please. And I'll be happy to. I'll give you a real quick example. For instance, about a year and a half ago, prior to my arrival, all pay rates were frozen. There were no raises, no cost of living adjustments, no nothing. The good folks here that have worked here and they worked here long before my arrival. In most cases, they joyfully did that. They took it upon themselves to say, we care more about the hospital in the area than we do our personal bank accounts in particular. That's one way. In essence, we've had to do it on the backs of our employees. We've also had to reduce some of the retirement payment plans to our employees. Those are really, really difficult things that also have negative economic ripples back through the community when you do that, because those are dollars that aren't necessarily going back into the community. That's just a shore of the losses that we've had. We're continually having to bring in physicians to provide services to make sure that we're able to provide the needs and meet the needs that are here, those come with a cost, just like a new piece of equipment comes with a cost. We managed to do a lot of that, not the recruitment of positions, but the equipment piece we do through grant funding to the extent possible. You know, like all of my other colleagues on the call and anytime that have testified in front of you, we just cobble it together. We don't have large revenue streams. We're all predominantly government pay. there was a conversation earlier about bad debts, and I don't remember if the gentleman was, but he painted it exactly right. We're obligated to seek payment in some of these cases. If you're seeing a Medicare beneficiary, you have to go after payment. Medicare requires that for you to get to even claim it as a bad debt expense on your cost report. You have to go after it. So it's just, you know, grit. The short answer, Brett Bointer, is it's just grit. We just grind through it my colleague Jennifer and Teresa and Adam and Julia we all we all have the same not in our gut every day when we come to work I mean it's how we're going to cobble it together today okay one final question vice chair leader thank you madam chair it goes to mr. Ron Hogan you had said there's times you have to go after the employees pay do you ever go after the CEOs pay mr. Sure. Okay. With that, I think we really appreciate your participation today, and we'll move on to our next support panel. Let's bring up Melanie Hoover, Daniel Colon Hidalgo, Rosio Leal, Aaron Ostell Madden. Let's just, can we just pull up an extra chair on the dice? Yeah, yeah. Totally fine. And we'd love to have you at the microphone anyway for questions. Here, switch with me. Okay. Thank you so much. And then let also bring up a few folks who are online Sorry just give me one second here We bring up Manuel M., Jim Powers, Arabi Mambangani, Amanda Boone. Okay, and then let's also try Anna Reid. And Maddie Schmidt. and then we tried Ms. Jade Kelly earlier let's try her again oh she's in person actually you know what we'll put you out if it's okay on the next panel okay I think any other folks online oh there we go perfect okay we'll start from my left to my right if you could introduce yourself the organization you represent and you have two minutes oh great okay Perfect. Welcome. And thanks for sticking with us this late. I think you might have turned it off. There you go. Lovely. Okay. Thank you, Madam Chair and members of the committee. My name is Melanie Hoover, and I'm testifying on behalf of my partner, Jacob Moore, as I am a faster speaker. We both live here in Colorado, and we are both here today in support of HB 26-1267. When Jacob first moved here, he was a welder and had very inconsistent income. Helping support me and my family, including my mother, a disabled veteran, was very limited income. He was a huge support and has been ever since. At the same time, he manages chronic health conditions. And in 2024, he faced two life-threatening emergencies, anaphylaxis and atrial fibrillation, also known as AFib, within the same week. both required ER care and left him with a bill for roughly $3,500. Despite being under the 250% federal poverty line, no one ever asked about his income or offered assistance when they would call for payments. And eventually the bill was sent to collections for the full amount. When collections would call, he explained that he couldn't pay as he was living paycheck to paycheck, as many of us are, while supporting my family. And again, no one assessed his ability to pay or warned him that if He didn't set up a payment plan. He could face judgment in court. Then on Friday 25th, just two months ago about, he was served papers demanding the full $3,549 plus their legal fees to avoid judgment. We didn't have that kind of money. So he spent the next two days scrambling, weighing his options, contacting family members to see if they were able to help, all while trying to work and focus on his responsibilities. less than 72 hours after being served, he went into AFib again while at work. And that was the first time since 2024. He was rushed to the ER at the same hospital responsible for the suit, where his heart had to be shocked back into rhythm, which was a traumatic procedure for me to witness. And when he came to, the first thing he said is, I'm scared of how much this is going to cost me. Although he did manage to find a way to pay that debt, the stress of facing judgment and possibly having his wages garnished caused immense stress, which likely triggered the AFib episode, and now he may face more debt and it also took away from our savings that we needed to get married Thank you so much for your testimony Please proceed Thank you, Madam Chair. There we go. Thank you, Madam Chair and members of the committee. My name is Rocio Leal, and I'm reading a story on behalf of a community member who could not be here today. It was in Spanish, but it's been translated into English for you all. My name is Manuela, and I live in Carbondale. On October 25, 2019, my face started to swell. My stomach was feeling lumpy, and I broke out in hives. My eyes were half closed from the swelling, and so were my lips. My daughter said, Mom, what's happening to your face? I'll take you to the hospital. But I said, No. I'm going to call the clinic. The last thing I wanted to do was to go to the hospital. When I had gone to the hospital before, I was left with a huge bill and was denied coverage. So I called the clinic to speak with my doctor and the secretary told me, ma'am, this is a very serious. You need to go to emergency room right now. My daughter made me go. I was admitted three days and left with a bill of $47,000. I applied to the hospital discount and they asked for my pay subs, ID of all my family members, bank statements, and vehicle registrations. This was during the pandemic and I barely had any income. But my bank statement showed a $2,000 deposit for my friend who was paying back alone. They asked a lot of questions about that deposit. A few months later, I received a letter that simply said I didn't qualify. They didn't screen me for emergency Medicaid, and I didn't know how to apply for it. I thought it was only for pregnant women. In 2021, I started receiving letters and calls from A1 Collections. Everything was in English, so I asked my daughter to translate it. But she didn't understand either. The words were strange, and they sent me a summons to appear in court. But I didn't know what it was for. My daughter's boyfriend had been deported from the court in Glenwood Springs, so I didn't go. I called A1, and they asked for $600 a month, but I couldn't afford that. I paid what I could. All of this could have been avoided if they have assessed me for assistance I qualified for. Thank you. We'll just move on down the line. State your name and who you represent. You have two minutes. Thank you, Madam Chair. My name is Carly Weisenberg. I'm a senior organizer with Center for Health Progress, and I'm reading on behalf of a community member who had to leave. He is a physician and had to get back to the hospital on call. Good afternoon, Madam Chair, members of the committee. My name is Daniel Colon-Hidalgo, and I'm a pulmonary and critical care physician practicing here in Colorado, and I'm here in support today of the bill, House Bill 26-1267. I want to share a recent experience. I cared for a patient in the emergency department who was clearly very ill. based on his symptoms and exam, there was a real concern for a life-threatening condition that required immediate evaluation. As I started to explain the need for tests and possible admission, he stopped me. He asked if we could avoid ordering anything at all. He asked if he could just go home. He wasn't confused. He understood the risk. He told me he was worried about the cost, that he could not afford another medical bill, and that he did not want to leave his family with debt. As a physician, that is an incredibly difficult moment. You're trying to treat a serious illness and your patient is asking you to hold back, not because they don't want care, but because they are afraid of the financial consequences of receiving it. What was most striking and honestly heartbreaking was that he was weighing the possibility of dying against the certainty of financial harm to his family and struggling with which was worse. This is not an isolated situation. For a patient who's already living paycheck to paycheck, wage garnishment is not a minor inconvenience It can mean not being able to pay rent not being able to afford food or losing basic stability for their family I taken care of patients who are already financially vulnerable and the idea of seeking care that could trigger that kind of consequence is enough to keep them away, even when they're seriously ill. This bill helps address this problem by creating reasonable protections against the cascading effects of medical debt. It allows families to seek care when they need it, follow treatment plans, and focus on recovery, not financial survival. when patients can access care without fear they come in earlier they do a better job and the health care systems function more efficiently this is not only good policy this is good medicine i urge you to support this bill and vote yes thank you for your time thank you we'll go ahead and move on down the line stage name who you represent two minutes madam chair and members of the committee good evening my name is aaron osley madden i'm a physician assistant who's worked in both emergency medicine and currently in solid organ transplant. I'm also a volunteer with Center for Health Progress. I'm here today to speak in support of HV 1267. In my roles, I've cared for some of the sickest patients in our health care system, patients whose survival depends not just on our care, but on whether they can afford it. I could share countless stories of how medical debt affects patient care, but here is just one. A patient I saw recently needs a simultaneous liver and kidney transplant. Because of his age and disease, proceeding with transplant would ultimately lead to a lapse in his insurance coverage before he could qualify for Medicare. So he told me he needed to wait at least one year to be evaluated. In my field, we have clear ways to assess prognosis. I understood his concerns, but it was risky to wait. I told him that he had a 20 to 30 percent chance of dying in the next three months. His response, I know, but I just can't. I'm already buried in medical bills I'll never be able to afford. Then he said something that I'll never forget. To be honest, I would just be better off dead. This is the reality of health care in Colorado. These moments are not just devastating for patients, they are devastating for providers. Often I question how long I can be a cog in this machine, knowing that I am negotiating down below the standard of care and evidence-based medicine to avoid real financial harms to patients. It's painful that my care could cause them to lose their wages, their house, their car, or their last bit of savings. And I know I'm not alone in this feeling. Of course, I know that the system as a whole is in crisis. I worry about my patients in rural Colorado every day, and I spend a lot of my days often working late to coordinate their complex care. But we cannot keep saying that patients are the source of systemic financial instability when the system is breaking on their backs. When you all are ready for the real fight, I will be right there with you. But today, you have the opportunity to do something real, something tangible, something right now, something that is meaningful to me and meaning to all the folks here that have experienced hardship because of aggressive medical debt collections. You can support this bill. Thank you. Thank you so much for your testimony. We'll move on line to Jim Powers. Thank you, Madam Chair and members of the committee. My name is Jim Powers and I would agree to Colorado. I'm merging you to vote yes on House Bill 1267 because of the fear of financial ruin should never be a consideration for a person seeking health care. In 2004, my wife, Cindy, he was diagnosed with a birth defect with a do-or-die surgery to correct. That one surgery started a chain of 18 additional surgeries over the next five years to either debride infection or attempt to repair the abdominal hernia. With the phone ringing non-stop from bill collectors, we went to a bankruptcy attorney in 2009 to try to protect our home. They ultimately found a quarter million dollars in medical debt, about $75,000 from the max out-of-pocket from our insurance, and the rest were bills that the health system failed to file claims with insurance for. This was their $175,000 mistake that we were stuck with. That was not our fault, and it cost us everything, including our home. To this day, Cindy still hesitates to seek care until things get really bad, requiring an emergency room visit. She fears debt collectors and losing our home again based on that experience. Her blindness on March 7th could have been avoided if she had sought out care when problems arose instead of waiting until she couldn't see to go to the ER. Not only did she lose her vision, requiring extensive hospital stay and complicated treatments actually cost the health care system more than if she had pursued outpatient care. For me, I live with extreme back pain for the last three years, fearing death from an expensive surgery. I finally gave in, and thankfully it won't be as bad as I had feared, but that is how we perceive medical care today, afraid of losing our home, and it should never come to this. For all of you on the committee, you need to understand this is not a partisan bill. I'm very conservative, but I see that this affects everyone in Colorado. You were elected by the people to represent the people, not the medical profiteers. If you have not been affected by medical debt collections, feel fortunate today, because medical debt collection is an equal opportunity offender, and it will impact everyone in the future if it hasn't reigned in today. Thank you for your time, and I urge you to vote yes for this bill. Thank you so much for your testimony. We'll move on to Anna Reed. Thank you, Madam Chair and members of the committee. My name is Anna Reed. I am a social worker and live in Arvada with my husband and two children. I am one of Representative Furey's constituents. I'm also a member of Center for Health Progress. A year and a half ago, our infant daughter was in the NICU. Just a couple of weeks ago, my partner and I received a collections notice for a bill from the NICU. We paid the bills that we got from our daughter's hospital stay, so we were bewildered to be in collections for a bill that we could have and would have paid. Medical facilities fail to properly communicate about bills all the time, as happened with my family, and people's lives are devastated when debt collectors go after their paychecks. We are all vulnerable to the failures of our health care system. All of us. I am a social worker with a master's degree in a household with a six-figure income, and I am in collections for medical debt. A number of other states, including Texas and South Carolina, have passed similar laws protecting people from wage garnishment. And there is no data that we have seen showing that hospitals in those states have closed or even lost revenue as a result. This is a matter of listening to your constituents and passing common sense protections. Many parts of the bill have already been stripped out or watered down, which makes me very angry. Please, please consider what is on the table now. Every family, including mine, including yours, deserves the modest protections that are in this bill. You have a choice today. You can choose to listen to lobbyists who are peddling fears and not facts, or you can choose to uphold Colorado's values of fairness and opportunity. This is a smart use of legislative authority in a very difficult year Please vote yes Thank you Thank you for your testimony We move on to Annie Martinez I think we actually already had Annie Martinez, so we'll move on to Amanda Boone. hi good evening good to see you all well from here not in person for this time um good evening and thank you for having me amanda boone and i'm the co-founder of cf united a grassroots organization focused on affordability and access for people with rare disease and complex medical conditions i actually live with that rare disease myself called cystic fibrosis and i've spent unfortunately most of my life living in and out of the hospitals. I relied on extensive therapies just to stay alive. For that, I can say I am truly deeply grateful for those providers and my nurses and the healthcare staff that took care of me, but it did also come with overwhelming medical debt. At one point, I was receiving collection calls while I was hooked up to an IV pole in a hospital bed, so it was quite uncomfortable because I was admitted on the sixth floor and getting a call from financial services, I decided to ask my nurse to help me with my oxygen tubing and IV pull. And I rolled myself down to financial services and I asked for charity care. I do have a little experience in this arena because I've been fighting all my life and I kind of know how to work the healthcare system. So I thought maybe I could get some help. But unfortunately, even at this time in my life, when I was really sick and an end stage CF, which means my body was failing. I had good insurance, but I could not qualify for charity care, even though I had no income. If I had a savings account over $2,000, then they would garnish those wages. And I still wouldn't qualify until after that was met. It was a really frustrating time for me and my husband and my young son at the time was waiting for me to get home. So what happens when you're denied for assistance, it's like your body can't heal the stress, the mental toll that it takes. It affects your recovery. It affects your ability to get better. And it affects you to really, in the end result, get out of the hospital. It's not just a financial issue. It's a whole holistic approach. It's a whole mental and physical issue. No patient should have to face this kind of pressure while they're trying to survive. Unfortunately, my story is not unique. Many patients in our community are struggling, especially after losing Medicaid coverage during the unwind, which you all know a lot more about than I probably do. Too often, the patient voice takes a backseat to private conversations happening in offices and hallways with stakeholders who have far more resources to influence those decisions. Thank you so much for your testimony. Okay. Any questions for this panel? Okay. Seeing none, we will move on to the next panel. Thank you so much for your participation. Okay, with that, we will bring up our next opposition panel. Let's have Megan Dollar, Parker White, Alison Lesko, Jillian Horkin. Benjamin Vinci Scott A Susan Price A'Laylee. We could just pull one extra chair up. Wonderful. Thank you so much. And then Dr. Kimberly Chow, who's on remote. Dr. Laura Eggerly Gibb. Dr. William Hilty. Any of those folks? Okay, great. We'll give it a second. Okay. Well, those folks are coming up. If you could, I'll go from my left to my right. If you could introduce yourself, the organization you represent, and you have two minutes. Good evening, Madam Chair and members of the committee. My name is Susan Price-Alley, and I am here today as a concerned citizen and healthcare administration professional. Thank you for providing me the opportunity to speak before you today in opposition of the House Bill 26-1267, which would be devastating to the healthcare industry and the patient population in Colorado. I have a master's degree in healthcare administration with more than 30 years' experience in practice management and administration of both private and hospital-owned practices. In all my time and experience, I can say with certainty that medical practices do send patients to collections lightly. In fact, that is the last thing we ever want to do and must go to great pains to avoid it. In most every case, it is only the patients that ignore the statements, the phone calls, or otherwise simply refuse to pay that gets into collections. It is always preferable to make a reasonable payment arrangement with a patient, but unfortunately, in many cases, that is not possible. Not because the practice isn't willing to accommodate the patient's financial situation, but because the patient simply won't respond. In these instances, it is necessary to turn the account over to our collections. In private practices, these unpaid patient balances are very important. The profit margins in primary care, for example, are very small, and they really need to be paid for all the services provided. Medical professionals deserve the same rights and ability to be paid for the services they provide as any other service provider in any industry. This legislation would, in effect, make it so that there would be no recourse a provider or their collection agency could do to be paid for the services if the patient simply choose not to pay. This will necessarily lead to more patients simply choosing not to pay once it becomes known that there is nothing that can be done to compel payment. This could result in providers requiring payment in full prior to treatment rather than current system of billing patients insurance and then billing patient for the portion they balance they owe Thank you so much for your testimony Please proceed Madam Chair members of the committee my name is Scott Alloly and I here representing the Associated Collection Agencies of Colorado Wyoming and New Mexico Thank you for the opportunity to speak with you today in opposition of this bill, HB 26-1267, which in effect is a bill that would ban all non-valuntary collection of every medical debt of any kind for any product or any service, regardless of the patient's ability to pay. We've heard it said today that most people pay their bills. That's a statement that I wholeheartedly agree with. Most people do. But unfortunately, some people don't. And that's where the necessity of our services for our clients that we represent in all industries comes into play. There are, in fact, some people who have the ability to pay who simply choose not to for various reasons. In those cases, there has to be a tool for the original creditor, the doctor in this case, to be able to recover the funds unjustly being withheld for the services they provided. Now, today we've heard a lot of testimony from some of the proponents and testifying in favor of this. And a lot of that testimony has been very moving, and I respect each and everything that everyone has said. That being said, I would like to point out and stress that in the last six years, this legislature has passed numerous measures addressing each and every concern that's been raised here today. none of the examples that i've heard could even happen today because of the laws that this legislature has passed in the last six years to this to pass this bill now is just simply a bridge too far that would be too harmful as someone represents someone mentioned earlier today too it would be much better to find a solution to to our cost problem rather than simply prohibit anyone from being able to be paid lastly there were some there's a lot of references to what other states do that is not analogous thank you so much for your testimony appreciate that please proceed thank you madam chair members of the committee good evening my name is parker white i'm the director of the colorado competitive council and c3 has taken an opposed position to house bill 26 1267 colorado already faces some of the highest health care costs in the country and policies that make it more difficult for providers to collect on medical debt do not eliminate those costs. They simply shift them. When providers cannot recover costs from services that were delivered, those losses are passed on to the individuals and the employers who do pay. Over time, that creates a cycle where costs continue to rise, fewer people can then afford care, and the affordability challenges that this bill seeks to address become even worse. We're also concerned about the broader precedent that this bill sets. At its core, this legislation moves Colorado towards a framework where individuals are less accountable for the costs associated with goods and services they utilize. If that principle takes hold in healthcare, it becomes easier to extend into other sectors. That runs counter to the basic economic expectations that support functioning markets and responsible financial decision making. Finally, healthcare costs are already one of the largest and fastest growing expenses facing employers in Colorado. Those rising costs directly affect wages, hiring decisions, expansion plans, and ultimately the competitiveness of our state. Employers are already contributing to statewide healthcare affordability efforts through mechanisms like the Health Insurance Affordability Enterprise and asking them to absorb additional cost shifting only adds strain to businesses that are already operating in a high-cost environment. For these reasons, we respectfully oppose House Bill 26-1267. Thank you for your time. We look forward to continuing to work with the sponsors and stakeholders to find solutions that improve affordability without increasing long-term costs for both employers and families. Thank you. Thank you so much for your testimony. Please proceed. Thank you, Madam Chair and members of the committee. My name is Megan Dollar. I'm here on behalf of the Colorado Chamber of Commerce. I am here testifying in opposition to House Bill 26-1267. The Colorado Chamber of Commerce represents employers across the state, including health care providers, small businesses, and rural employers. While we support fair treatment for patients facing medical debt, we are concerned that this bill will create unintended economic consequences that will increase costs and reduce access to care. First, the bill significantly limits providers' ability to recover legitimate medical debt. These costs do not disappear. They are shifted. That means higher insurance premiums for employers and higher health care costs for worker families. Second, the bill adds new compliance requirements, liability risks, and administrative burdens. For many providers, especially rural hospital and small practices operating on thin margins, this could reduce financial stability and threaten access to care in underserved communities. Additionally, by making repayment less predictable, the bill could reduce access to patient financing options and lead providers to require more upfront payment, limiting flexibility for patients. In short, House Bill 1267 shifts costs and risks destabilizing parts of Colorado's health care system, impacts that will ultimately be felt by employers, employees, and communities across the state. For these reasons, we ask for a no vote on House Bill 1267 today. Thank you so much for your testimony. Please proceed. Thank you, Madam Chair. Is my mic on? No. I hit it. Oh, it was on before. Thank you. I'm here testifying in opposition today. My name is Ben Vinci. I'm a Colorado native. I'm also an attorney who's been licensed practice law here for 31 years. We all know here today that this bill will not change the issue we have with health insurance in this country. That is a fact. We need to change the health insurance in this country. This bill does not address that at all. I think everything pretty much that I have written down here has already been covered, but there are two topics I want to cover. One is the question would become why would somebody maintain health insurance if this bill passes? In the state of Colorado, there's going to be no reason to maintain health insurance. And I'm going to tell everybody I know, cancel your health insurance. There's no reason. You don't have to pay for health care in this state. It's all going to be covered by who? I don't know. It's just ridiculous that we're here today when we know that the people who provide the health care have to be paid. They have to be paid somehow, some way. And if people are refusing to pay, and we've heard the testimony that only the people who refuse to pay that can afford to pay are the ones that get sued. health care providers and collection agencies aren't going to sue low-income people that don't meet the test for being garnished. The other thing is I'm going to tell all of my doctor friends, my dentist friends, don't accept any patients unless they pay up front. And so that going to put a chilling effect on all those small offices Lastly I heard at the very beginning with the supporters of the bill that they were talking about Texas And I'm not a licensed Texas attorney, but I do know the process in Texas, and it's totally misguided what they're telling this committee. What happens in Texas is if you get a judgment, then that judgment creditor can appoint a receiver. and that receiver then takes over the finances for that judgment debtor. And then they don't have a choice as to who they pay. It's just like in a bankruptcy. I'm happy to take any questions. I would like a vote of no on this. Thank you. Thank you so much. I don't think you said your name in your testimony, if you wouldn't mind. Benjamin Vinci. Thank you so much. Ben. I said Ben. Oh, no problem. Sorry if I missed it. Just wanted to make sure it was on the record. Thank you. Okay, we'll move online to Kimberly Schau. Hi, thank you for allowing me to speak. My name is Kimberly Shao, and I am a physician in Lakewood, Colorado, and own a small independent practice that relies on being paid for the services we provide, not only to remain afloat, but to pay our employees, who we view as family, a fair and decent wage. It also allows us to provide timely care to our community and continue to be one of two practices in our area that sees Medicaid patients. Independent practices must have the same rights to pursue payment as any other industry. While I wholeheartedly believe healthcare is a right, we do not live in a country with universal coverage. While I would like to wholeheartedly believe that all my neighbors want to pay their bills, many do not, despite transparent pricing, sending multiple statements, offering payment pens, and using collections as a last resort. I personally reached out to patients to discuss their balances. I've personally taken the time to explain what deductibles and coinsurance mean. I've personally written off debt when patients were upfront about their situation. I even volunteer with ITASC, an organization that provides pro bono cancer surgeries for patients in need, but the choice to absorb that cost should remain with physicians who understand their own financial realities. Even as a physician, I know what it's like to be on the patient's side and face large medical bills. My husband was recently diagnosed with lymphoma, and our bills are tens of thousands of dollars. Managing finances and juggling multiple loans while just trying to survive is emotionally exhausting, but we've worked with each of the hospitals to come up with payment plans as the doctors treating him deserve to be paid without litigation. As many have already said, and I echo the same, a majority of patients, yes, they want to pay, but there are some who, even despite calls, their debts go unpaid and the phones go unanswered. House Bill 1267, as it stands, does not discriminate between small independent practices and large healthcare organizations that may be able to absorb these costs, especially the newly established small practices with minimal reserves. And this bill punishes physicians by not only eliminating potential avenues for obtaining payment, but by also applying penalties of up to $3,000. We must protect patients, but not the cost of destabilizing independent medical practice that communities rely on. Thank you so much for your testimony we'll move on to Allison Lesko. Hi sorry that my video is not wanting to play so well thank you Madam Chair and committee members for your time today my name is Dr. Allison Lesko I'm a general dentist and a private practice owner in Fort Collins for the past 10 years and I'm on the board of trustees for the Colorado Dental Association. On behalf of myself and the CDA I would respectfully ask for your no vote on House Bill 1267. While I understand and appreciate what the bill sponsors are looking for to achieve I do have concerns about the challenges that this bill presents for small independent dental practices and other independent health providers like myself My practice is an out with many insurances and the issue with being out is that neither the patient nor the provider is privy to what the insurance companies will actually pay for the procedures until it's completed and the insurance filed. This means that while we do present our full treatment costs and our best estimate of what insurance will pay, the likelihood that the patient will have an out-of-pocket expense once insurance pays is a very common occurrence in my practice. Private practices often operate on thin margins, and while patients do not pay balances, those unpaid balances are not just a loss of profit. It's the difference between covering staff payroll, supplies, and keeping our doors open. While utilizing collection actions for unpaid bills is our very last resort, removing our ability to collect shifts cost to providers and ultimately to patients who can and do pay. If this bill were to pass, it will create a shift in the dental practices where the patient would be required to pay in full prior to any and all dental treatment and expect reimbursement from their insurance. This action would create an unneeded access to care hurdle, which would prevent many patients from moving forwards on the dental care and thereby increasing the likelihood of dental emergencies seen in the hospital emergency rooms. I'm also concerned that for our patients, could see reduced access to healthcare financing options, such as Care Credit, which is a financing company that allows patients to pay for their dental treatment over time. These companies may consider limiting who they offer financing to, as they too would be impacted by their limited ability to collect dental debt. That outcome could also work in access to care. We as a profession are very supportive of protecting patients, and the CDA is proactive in pursuing legislation to make dental insurance more meaningful for patients. However, we oppose forcing small businesses to absorb the impact of unpaid dental bills, even for patients who have the means and the ability to pay. Thank you so much for your testimony. We'll move on to Laura Edgerly. Sorry, I was muted. Hi, my name is Laura Edgerly-Gibb. Thank you to the chair and members of the committee for allowing me to testify in opposition today. I'm a rural ER doctor, and I'm the current president of the Colorado American College of Emergency Physicians. I'm also a partner in a private Colorado-based emergency physician practice that specializes in rural emergency care. I want to specify that I have not had access to any of the strike below amendments discussed in the introduction, and I'm speaking specifically in regards to the bill as originally written. I have significant concerns about how this bill would affect small physician practices in terms of the significant administrative requirements and fines imposed, as well as, which was previously covered by previous testimony, our rural hospital partners. In my practice, we work with our patients in every way possible to provide payment plans, provide discounts, and charity care. If insurance information collected is collected incorrectly, we work with patients to make sure we have the appropriate information. As you know, emergency physicians work on the front lines of America's health care system. We provide care 24 hours a day, seven days a week, 365 days a year to patients, regardless of insurance status or ability to pay. In 2025, RAND published an extensive report of the dire state of emergency care in the U.S. and outlined the significant threats to the emergency system. One of the major threats the RAND report outlined is the financial impact of EMTALA and declining reimbursements on our emergency system. While EMTALA mandates care, it is completely unfunded. ER physicians comprise only 4% of the workforce, but in 2023, we provided two-thirds of the acute care visits for uninsured patients and provided billion in unreimbursed care nationally 20 of ER visits are simply just never paid With House Bill 1 and declining Medicaid enrollment rates we expect those numbers to continue to increase as the number of uninsured patients continues to grow. The types of limitations, administrative burdens, and fines in this bill can lead to practices like mine either closing or selling to private equity. And we know that the expansion of private equity means decreased health care competition, increased health care costs, and most importantly, worse health care outcomes. I ask that you vote against 1267 so we can continue to care for callers patients. Thank you. Thank you so much for your testimony. Do we have Dr. Hortman is being added? Great. I see her hand up. I don't. Dr. Hortman, if you want to unmute and begin your testimony. Thank you. Sorry, it took me a minute to get connected. I appreciate your time. Thank you, Madam Chair and committee members. My name is Dr. Jillian Horgan. I'm a general dentist and private practice owner in Manitros, Colorado. I'm a board trustee for the Colorado Dentist Association, and today I represent myself and the CDA. I'm respectfully testifying in opposition to House Bill 1267 because the bill, as written, would unintentionally undermine access to dental care and undermine the financial viability of small practices just like mine that serve Colorado communities across our area. Yeah. We're grateful for the decisions and discussions that the sponsors have been willing to have on this bill. And we appreciate the movement that they've agreed to after hearing concerns. But unfortunately, our concerns for small business and dental offices remains even after proposed amendments. The provisions of this bill and the proposed amendment would unfortunately allow patients who have the means to pay the dental bill to skirt that responsibility with little means for the dental office to actually collect on a bill. As stated before, it does take tools out of our toolkit. The intent to protect patients from an overzealous and aggressive debt collection is commendable. However, this bill imposes regulatory framework that is fundamentally mismatched with the reality of small private dental practices. Dentists like myself are not in the businesses of sending our patients to collections. We work with patients on treatment planning that meets their oral health needs and fits within their budget, as well as offer payment plans and access to health financing to ensure patients can get the care they need in a way they can afford. Sending a bill to collections is a last resort, if even chosen, and it's one that's not taken lightly. Debt for traditional dental practices is also typically much lower than that of medical debt. So when small businesses like dental practices have to absorb these relatively lower costs across multiple patients, we risk having to write off a notably larger portion of our business unpaid debt and risk the viability of our dental practice itself. This would be particularly harmful for access to care in Western and rural Colorado, where we have fewer providers available to even provide dental care. And while the goal of protecting patients is paramount, the current language of a House Bill 1267 would remove tools that small practices rely on to cover legitimate documented balances. Thank you. And reduce our capacity of dental practices offering small sliding care as well as Medicare for patients. Thank you so much for your testimony. Okay. Moving on to questions from the committee. Representative Brown. Representative Luke. Is it Mr. Lully? How do you say that? Forgive me. No problem. It's Alalee. Alalee, yes, thank you. And it's late. I had it in my mind, and thank you. Can you tell me a little bit about the notices that are already required that you provide? Mr. Alalee. Thank you. Thank you, Madam Chair. If I may, are you asking about the notices that a collection agency only has to provide or the notices that the patient will be provided from the health care provider through the collection agency? Representative Wook. Yes, the latter. Mr. Alley. Thank you.
Yes, there is only one notice that's required under Colorado law of a health care provider to send, a non-hospital health care provider to send to the patient. However, the typical practice in my experience and with the more than 200 practices that I represent in the front range area is that a health care provider will send one general statement after the insurance has processed the claim. Typically, they will send one other statement before they send what we call the final demand. The final demand is required under Colorado statute 620-202, I believe, and has been for many, many years. This is a statement that's required by Colorado law notifying a patient who had insurance of any kind that the insurance has been processed and the remaining balance is the patient's responsibility, and it gives the patient no less than 30 days from the date of that statement to contact the provider to work out some sort of an arrangement. That's what's required. If the account gets sent to the collection agency, then the collection agency is required by federal and state law to send what's called a validation notice to the patient, letting them know that the account's been assigned to collection, notifying them of their rights of that assignment, and giving them no less than 30 days, typically now it's 38 days, to respond. That must be done before anything else can even begin to happen.
Vice Chair Leader.
Thank you, Madam Chair. And this is also for Mr. Olloli, if I heard it correctly. You stated that because of all the laws that have been passed here in Colorado, that this possibly couldn't be a problem or couldn't be true. So can you clarify if I'm misunderstanding you? So then are you saying all the stories that we heard from the people today were not true because of all the laws that we passed today?
Mr. Allen.
Or not today but throughout? Thank you.
And no, that is not what I was getting at. I believe every word practically that I've heard today. What I was saying is that in listening to the testimony, the accounts that I've heard were almost entirely things that had happened years ago, long before any of these new laws had passed. For instance, specifically the accounts of wage garnishments. Colorado passed dramatic wage garnishment laws just in 2019 that, in effect, allow a patient or a consumer to have any garnishment reduced, if not entirely eliminated, based on financial ability. Those laws did not exist when the accounts of bad experiences were retold today. One was from 2002, some were from long earlier. That's just one example. We also have bank garnishment laws that are much different that also did not happen back then These are all consumer protections that did not exist when these other testimonies were being related I'm not discounting them in one bit. I'm just saying that Colorado has already addressed those issues successfully.
Vice Chair Leader.
Thank you, Madam Chair. What I heard today was there was some in the past, and there was some that was happening right now. and I have gotten collection notices. Well, I should say my family's gotten collection notices and it was due to the fact that they were billed incorrectly and I heard a whole lot of that in here because the hospital, the provider did not bill them correctly. They did not bill the secondary insurance or they built the secondary insurance and instead of the primary insurance or vice versa and then for whatever reason, they can't get the secondary insurance correct and that they're sure, even though we'll call and say, hey, this was not billed correctly, but I already got a collection notice on the back end of that one in the middle of the dispute of the original charge. And I heard a lot of that, and I know that's for a fact, and that's happening right now. And anyone that would, you know, not want to take insurance, and I believe this was said by the gentleman on the end, and any provider that wouldn't want to take insurance, I wouldn't want to go see a provider that wanted to put profits above people. Thank you.
Representative Johnson Thank you Madam Chair I think it was Ms. Dollar that mentioned this but anyone on the panel I heard that it could be if this bill would pass we could see a lot more of providers needing to have payment up front that could be a barring too so instead of having access to care and then trying to figure out the payments you don't have access because you can't pay did I hear that correctly that could be where we're leading
which is very concerning. Ms. Dodd. Thank you, Madam Chair. Thank you for the question.
I'm probably not the best person on this panel to answer the question, but I will say that yes, that is feedback that we receive from our members that would be the practical effect of this bill. Representative, oh, we have Dr. Lesko. Did you want to answer that question? Yeah, this has been a big discussion, especially in dentistry. And from a standpoint of, the larger hospitals we understand and we empathize where this bill is coming from. But it does create an issue for us where we have insurances that we may not know what they cover of our fees. And so it's really common for having patients either on a payment plan or having them have a small out-of-pocket expense afterwards. And so it leaves us with that risk of what if they don't want to pay and what if they choose that they don't pay and we can't do anything about collections on something that we have already done a lab bill or treatment for. And so the vast communication with a lot of the dentists here in Colorado have been that we would need to change some of the pay structures, which would be an access to care, because I do feel like it's unfair to ask the patient to pay up front and full for a treatment that we knowingly know that and expect an insurance to cover a portion of it.
Mr. Vinci. Vinci. Vinci, sorry. Just like Leonardo da Vinci. Got it.
Just to clarify my testimony, my testimony was specifically with regard to I believe the health care system is broken. And I believe the experience that you're experiencing, a lot of people experience, including me. But this bill, I don't think, addresses that. That's the problem. I don think that this bill addresses that The testimony that I been hearing all night at least in opposition is that the garnishment and those processes are a last course of action This is a last course of action for the folks that are not voluntarily paying. My testimony is these health care providers have to get paid to stay open. They won't be able to stay open if there's no enforcement.
It looks like Dr. Horkin would like to answer the question.
Yeah, I just want to add, too, that I think a lot of the testimony we've been hearing in support of this bill has absolutely touched a lot of people's hearts. And many of us are in similar shoes. I've been to my own hospitals where they have inappropriately billed miscoded. And this bill does nothing to address those things. So we're talking about a very small percentage of, while wrongfully predatory practices by insurance or by collection companies, but that's not where the majority of the problem is. And this bill doesn't cover the actual issues in health care and the reasons why people are getting these collection notices and garnishments.
Representative Bradfield. Thank you. This question is for Mr. Alley. You mentioned that legislation has been passed since 2019. In fact, there have been seven bills. Could you, for what you remember, could you kind of go over what some of those bills are and what the purpose in consumer protections may be? Ms. Rowley. Thank you. Yes, Representative Banfield.
Yes, I happen to have a cheat sheet. Briefly, as I mentioned, there was a bill that addressed wage garnishment changes back in 2019, which dramatically reduced the amount of money that could be withheld from a consumer's pay and also expanded the exemptions that they can have. And in addition to that, it afforded every consumer an opportunity to have that garnishment reduced even further, if not completely eliminated due to their financial situation. That was in 2019. Also in 2019, there was legislation dealing with out-of-care network healthcare services, which was beneficial to non-contracted consumers. There was in 2021, you had the indigent care bill, which looped in not only nonprofit hospitals and even for-profit hospitals, but it also looped in every provider that practiced in those hospitals for the services that were provided in the hospital, requiring them to offer and apply indigent care programs for consumers and limits the payment plans based on income, household income, and also limited the duration of payment plans. plans then in 2023 we had medical transparency legislation was passed and also we had the banning of medical debt being reported on consumers credit reports in Colorado which what that was in 2023 and in actuality it didn't ban the reporting so much as it bans the lenders ability to score the consumer based on a medical bill. I can relate that passage of that bill dramatically reduced the number of patients who have paid off of the first notice that we send because they do not fear credit reporting anymore We also in 2024 we had the Equal Justice Fund wherein whenever a consumer is sued by a collection agency, there's an additional $10 fee tacked on to the filing fee of the case that goes to help support Colorado legal aid for patients who qualify. And finally, we had in 2024, we had regulation dealing with dramatically changing how these lawsuits have to be brought, whereas every single lawsuit the collection agency brings must include in the case caption the name of every single healthcare provider that they're representing in that case, as well as the pleadings must include a redacted, detailed itemization of the actual charges that the agency is seeking payment for with the court. In addition to that, before a default judgment can be entered, the agency must provide certain other affidavits and detailed itemizations of any post-assignment charges or credits. That's, at best of my memory and by my cheat sheets, the ones that have passed since 2019. There were many others earlier than that.
The time for this panel has passed, but I'll do one more quick question from Representative Bride. Thank you, Madam Chair. It's also to Mr. Alley. I also have been tracking some of the testimony that we heard about things that probably happened before those laws were passed, and so I'm mindful of that, but there was one testimony that kind of stuck with me that happened more recently where they said that they got notice and they tried to go to the hospital to address it with the billing department. At that point, they were kind of like, you're out of luck. Now, my understanding is the way the law has written that that actually is an illegal behavior and that everything has to stop when that individual has tried to negotiate or at least has said, hey, I have a problem with this bill. Is that accurate? Ms. Rowley. Thank you. Yes, Representative Bryden.
I honestly don't recall the exact details of that testimony, but I vaguely do. and as far as what would be legal and what would not be legal would be determined by who the original creditor was, whether there was insurance or not, and things like that. And there's some timing issues there. If the testimony was that it was a hospital that the patient was trying to communicate with and the debt had already been assigned to a collection agency, then I would assume that I'd have to presume that the 182-day minimum had already past. And in those cases, typically, in my experience, again, without knowing the facts of that case, in my experience, once a health care provider is assigned an account, formally assigned the account to the collection agency, the preference is that all communication go through the collection agency. As I believe Mr. Boettcher commented on earlier, whenever they get a dispute like that, their policy, as is mine, is to cease all collection activity, go back to the hospital or the doctor's office, relay the dispute, try to get the facts so that you can properly respond. I'm sorry I can't be more specific without remembering exactly what was said.
Thank you so much for your testimony. We appreciate you participating today. Okay, or tonight, we will move on to our next support panel. Sandy Lamb, Myesha Fields, True Apodaca, Jade Kelly, Nicole Survea-Loy, Naomi Amaha, Megan from CCH, but I don't have a last name. Megan is in the house. Okay, great. Do we have any folks online? These are from June. Here we go. Can you pass? Do you mind? Sorry. Okay. And let's also call Brandy Marcus. Megan Nofney. Oh, great. Okay. Brzei Gomez. Erin Osteel Madden? You already met. Okay. Sorry, guys. The amount of folks have... Yes, apologize. Dana Kennedy? She's good. Doesn't need to testify. Okay. Jess. Oh, we already covered. Okay. Any other... Let's see here. Online. Let's try... I think I already called. Yeah. I don't think so. Robby Monbingani? Okay. Go with those folks for now. Okay, we'll start in person. Thank you all so much for your patience tonight. If you can introduce yourself, the organization you represent, and you have two minutes, if you could just push the little button by the plug. Got it. Great. Thank you, Madam Chair. My name is Jade Kelly, and I'm president of CWA Local 7799, representing thousands of workers across Colorado in the public sector, including health care workers at UC Health and Denver Health.
I'm here to support this bill on behalf of our union members, but also because I have a personal axe to grind for what's happened to me and my fellow CWA members at UC Health. I've been personally sent to collection over a dozen times, usually for $30 or $40 charges that show up weeks or months after I've already paid my copay, after insurance has paid, after I've done everything right. These bills come with no clear explanation for what they're for, no easy way to resolve them, and before you can get on the phone to fix it, you and your mother are already getting blown up by Tina from collections. Our members at UC Health, nurses, doctors, tech, staff, the very people who keep our healthcare system running are being sent to collections by their own employers or their wages garnished for the care they received at work from their coworkers. Let that sink in. You dedicate your life to healing people. Work 40 to 60 hours a week, and instead of a living wage in medical care when you need it, your reward is medical debt from your own employer who's telling you you are too poor to afford those services that you provide. That's how broken our health care system is. And trust me when I say I deeply understand that this isn't the only problem we have. But I need to push back against the claim that this bill is about protecting people who refuse to pay, or that this bill is about targeting rural hospitals or that we should trust a CEO who's clearly pitting patients against workers who forgets the simple truth that workers are patients and patients are workers and there's only a handful of folks at the top who are negotiating these rates and setting the wages. This bill is about putting a check on the most abusive parts of our system the large hospitals and the most aggressive bad actors like UC Health who have weaponized debt collectors in our courts against working people often for small confusing disputed charges and when asked questions, they blame insurance for the additional charges, wash their hands, and send you to collections like clockwork. This bill is clarity, protecting patients and preventing abuse, and making sure that the sick do not get dragged into court or that a $30 charge doesn't result in a court date and a massive hit to your credit score. This is about restoring some balance in our system that has tilted too far towards profit and away from the public good. Vote yes on behalf of CWA.
Thank you so much for your testimony. Please proceed.
Thank you. Good evening, Chair Gilchrist and members of the committee. Thank you for the opportunity to testify in support of House Bill 1267. My name is Naomi Amaha, and I serve as the Director of Policy and Government Affairs for the Denver Foundation. The Denver Foundation is a community foundation that has spent the last 100 years connecting and collaborating with community members to address current and future challenges. Through our grant-making, partnerships, and fundraising, we have supported efforts to respond to our community's most pressing needs. This work includes providing an impact investment to support a small-dollar loan program for employers to offer their employees access to a low-interest loan when an unplanned bill, such as a medical bill, arises. We did this because we know unpredictable expenses create additional financial burden for families, undermining housing and food security, as well as their ability to achieve economic opportunity. Medical expenses are not something people choose to take on, and they can't anticipate medical care needs compared to costs associated with owning a car or going to school. The average person is only one emergency or crisis away from medical debt and those impacts. We support this bill because we believe it helps protect individuals and families so that getting sick doesn't mean financial ruin. This bill is an opportunity to build guardrails to support vulnerable Coloradans and standardized procedures for medical debt repayment. With the impacts of federal law changes to Medicare delivery in our state, it's now important to have a framework that patients and providers can each understand and follow. We want to thank the proponents and stakeholders for their deep work to address the complexity of and impacts of current medical debt collection practices, especially on low-income and working-class Coloradans. In closing, we believe this bill provides necessary consumer protections and will help with the financial stability of thousands in our state for years to come. Thank you, and I respectfully request that you vote yes on this bill because it's very important and timely. Thank you.
Thank you. Please proceed.
Madam Chair and members of the committee, my name is Megan Novotny. As a nurse at Colorado Coalition for the Homeless and a leader with Center for Health Progress, I'm here to discuss both organizations' support of this bill. This bill must pass to protect my patients, coworkers, and myself from predatory debt collection. health insurance and medical bills are unnecessarily complicated in our country people encounter confusing charges a system that is difficult to navigate lack of clarity on the cost of care and bills with clerical errors and overcharging my unhoused patients at cch already spend numerous hours each day navigating complicated systems such as retrieving their mail applying for benefits and trying to make it to job interviews without adequate transportation they need the protection of this bill so their money is not taken from their bank accounts as they try to find stability while facing extensive barriers. Of course, eliminating wage garnishments also allows people to pay their rent and prevents people from slipping into homelessness. My co-workers and I also need protection of this bill. Everyone does. UC Health has sued at least one of its own health co-workers for medical debt, and it is heartbreaking for me to think of this happening to one of my co or myself after working tirelessly to care for our community Additionally as a nurse and irreplaceable member of our health care system I burnt out from working in a system that discourages people from seeking care due to fear of poverty It is the reason I left hospital nursing after only five years and have met numerous nurses that feel the same, including two that I interviewed for jobs at CCH just this past week. Squeezing patients for money they don't have doesn't save a nursing shortage. It worsens it. Lastly, I want patients to trust me and trust in health care. How would you feel about health care if you were sued for medical debt? Would you feel comfortable seeking health care when you need it? Probably not. Everyone is healthier when we stop practices like suing patients for medical debt. I urge you to vote yes on this bill.
Thank you so much for your testimony. We'll move on to Arabi Mabingani.
Thank you very much, Madam Chair and members of the committee. My name is Arabi Mabangani. I'm a community member. I'm grateful to have this opportunity to advocate in favor of HB 1267. My family, like many others, has been ravaged by the weight of medical debt. And my father, who passed in 2023, suffered from chronic back pain for many years. and I saw him go in and out of treatments and surgeries. And unfortunately, his focus could not be fully on his recovery and health, but rather on the growing pressure of the medical debt that was being accumulated. As the treatments went on, payments became more difficult. Our family struggled to keep up and the financial stress was immense. And my father, in his final days, was unable to enjoy a good quality of life, in large part due to the crushing weight of medical debt and the guilt and the fear for our family's well-being. And it is harrowing to think that those thoughts may have been some of his last. I share the story to highlight the cruelty that medical debt imposes on individuals and families. And this kind of financial stress should not be a focus for families going through a health crisis. and unfortunately my story, the story of my family, is far from the only one. And this bill provides us with a unique opportunity to alleviate some of the weight of medical debt by, at the very least, limiting collection. And this allows families more space to focus on health and recovery without having to worry about losing basic financial stability. And this also helps to just grant dignity in the incredibly difficult process of addressing health crises. Thank you very much for your time. And again, I urge you to vote in favor of HB 1267.
Thank you so much for your testimony. We'll move on to Brandy Marcus.
Hi, thank you. Thank you, Madam Chair and members of the committee. My name is Brandy Marcus. I'm a community member living in Colorado Springs. I'm here to ask you today to vote yes on HB 26-1267 because I've been through wage garnishment for medical debt myself. A few years ago, I was left with a bill I couldn't pay in full from an ER visit at UC Health Memorial. At the time, I had private insurance and a high deductible plan, so I wasn't screened for financial assistance. I tried to work out a payment plan with the hospital, but the short payoff period they offered was unreasonable. I couldn't pay it off in six months and still pay my family's bills. They told me this wasn't my only option or they'd send me to a debt collector. I was hopeful that maybe the debt collector would offer me a payment plan I could afford They didn Instead an in collection lawyer sued me for the debt Sometime afterward my wages were garnished for six months They took about 20 of my take pay which after taxes and deductions, like insurance, was closer to 50% of my pay realistically. At the time, I was already living paycheck to paycheck. The wage garnishment put a significant strain on my family during a time when I was already in the process of a divorce and the added stress of splitting households. But it also damaged my credit because I wasn't paying. I was playing bill roulette. And in order to keep paying for groceries and utilities, I couldn't pay off my credit card debt and got behind on other essential bills. My credit card accounts were closed during that time. I worked overtime 55 to 60 hours a week to keep us afloat, which resulted in less time with my kids and less care toward myself. Plummeting my mental health and leading to significant burnout, I am still repairing my life and credit from wage garnishment. As a newly single mom, at the time, it left me in financial hole while I was trying to survive and build a stable life for my children. Debt collectors force people to do survival triage, picking and choosing between medication, food, housing, or electricity. I'm here today because this bill would have helped me protect my family instead of stealing my wages. I urge you to vote yes. Thank you.
Thank you so much for your testimony. We'll move on to, I'm so sorry, Ms. Bray. It's so small. Thank you. Sorry, it was just the letters were really small. Please introduce yourself and the organization you represent. You have two minutes. Thanks for being here.
Thank you. Hi, everybody. My name is Dizai Gomez-Cortez. I'm the Community Organizing Manager at Metro Caring, a Denver-based anti-hunger organization, and we're here in support of Top 67. Each week, we currently, right now, we currently serve around 3,000 households. We do this for our navigation resources in our no-cost grocery store model market. Out of these 3,000 households we see every week, about 1 in 10 community members are there seeking food assistance because they're currently dealing with medical debt. We've sat with community members who have to skip meals so they can make payments on medical bills and who are then harassed by debt collectors for debts they're struggling to keep up with. Medical debt is not just a health issue. It's a food access issue. It's a housing issue. It's a dignity issue. Families are choosing between paying a medical bill they did not expect or keeping the lights on. Between asking for medical support or putting food on the table are the questions that they need to ask themselves every paycheck. Coloradans need reliable access to adequate, affordable food that they can access with dignity and agency. But when medical debt drains their resources, that becomes impossible. It becomes less than a priority. As federal protections weaken and continue to fail us, states have to step up, and that responsibility sits here with you in this committee. As members of this committee, you are entrusted to represent the people most impacted by these systems, not corporate greed that keeps the systems in place. You represent the families and individuals that do not have the luxury of observing unexpected medical costs, the people who are already being pushed to the edge and making impossible choices to survive across the state. This is not about people failing to pay their bills. It's about assistance. that is failing the people. You are elected to represent everyday Coloradans. It's your duty to change conditions that may cost someone's stability, security, and ability to feed their family, even if it's one small step at a time. So on behalf of Metro Caring, I ask the committee to vote yes on top 67.
Thank you so much for your testimony. Any questions for this?
Representative Biden. Thanks, Madam Chair. I think it's for Brandy virtually on the wall. um what year was it that that happened to you ms marcus um the garnishment was i believe 2023 okay additional questions from the committee seeing them thank you all so much for your
testimony and for staying so late okay we will move on to our um additional opposition panel Let's bring up Dr. Hilti, Dr. Hill, Dr. Robinson, Dr. Promenko, and Dr. Hughes. I think all those folks are doctors. I apologize if you're not. Let me know if you need me to repeat those. Let's move. Repeat. Yes. Hilti, Hill, Robinson, Promenko, and Hughes. Hughes, yeah. While he's working on pulling those folks up, let's also add Stephen Wilson, James Wolfe, Vance Abeyta, Okay. With that, we will start with in-person. Thank you all so much for staying so late. We'll start from left to right. If you can introduce yourself, the organization you represent, and you have two minutes. And then if you could just push that little button by the plug, it should turn green. Thank you. Good evening, Madam Chair and distinguished members of the committee. My name is Vance Abeda. I'm the co-owner of ASAP Services, a process-serving company here in Denver, along with my colleague, Stephen Wilson. I'm also a Colorado native, father of six, and current medical debtor. So I know firsthand the challenges families face when opening our doors. Our dream was to build a good quality life for our families, but this bill threatens that dream. The people arguing in favor of this bill don't realize the harm it'll do, but they will when they seek out treatment and find that their doctor office is no longer open. And if they're lucky enough to find another provider, that the wait time for treatment could rival that of Canada. This bill will disrupt the medical industry in our state. If passed, I personally don't see incentive of having medical insurance. If my credit report isn affected and my property and my monies are untouchable medical debtors are by far the most protected in Colorado We served thousands of these summons that start the litigation process in many of these cases And the majority and I talking 90 or better have 2023 and newer vehicles in their driveway. The litigation that went into effect last March gave medical debtors unprecedented protection. It made the pre-litigation communication time between collectors and debtors before litigation caused many in the medical field to go months without a paycheck. It directly affected us so much, in fact, that our company took a 30% loss in revenue from our largest medical collections client. Steven and I also went months without being paid. As stated before, I personally had medical debt, and although I pay my bills as outlined by my payment agreement with my providers, I purchased an expensive Lego set yesterday knowing I could have taken a bigger bite out of my medical bill, but chose not to. This bill will allow that kind of negligent choice to be made, not in addition to making a medical debt payment, but in lieu of making one. Litigation is for the unwilling, not the unable. I know there are exceptions to every rule and have zero doubt that those opposed have had some horrible experiences. And I also have zero doubt that those experiences are not common practice and are anomalies. You've heard several providers testify that the percentage of cases sent to litigation is minimal, and those garnished is even rarer. The ramifications of this litigation aims to send significantly more people into financial hardship than it will protect from it. Part of this bill is in the right place, but what it's proposing is good for the few and harmful to the many. Thank you so much for your testimony. Please proceed. Good evening, Madam Chair and members of the committee. My name is Steve Wilson. I'm a partner at ASAP Services, a process-serving company in Denver. I grew up in Aurora, and I am here as a constituent and a small business owner to share the direct impact this bill will have on my company. This bill will likely put us out of business. My company serves legal documents. That is what we do. When a firm files a lawsuit, we deliver a summons. When a court enters a judgment, the creditor seeks to enforce it through wage garnishment. We deliver those documents to the employer. We are not a collection agency. We are not a creditor. We are the downstream service provider that executes lawful court processes on behalf of those entities. When we serve the documents, many of our clients include a note that says, if you want to resolve this prior to court, please give us a call. We will work with you. And that's usually on top of the summons, in the front. I want to be clear about what this bill means to our practice. Between 70 and 90% of our annual revenue comes from medical collection clients. If medical creditors can no longer garnish wages, they lose the primary enforcement tool that makes filing a lawsuit meaningful. If there is no reason to file the lawsuit, there is no summons to serve. And if there is no garnishment order to deliver, that work disappears entirely. It's not just the garnishments that go away. It's an entire pipeline. The lawsuits stop. The summons stop. The garnishment stop. My company loses 70 to 90% of its work. This is not hypothetical. We've already experienced measurable contraction. Revenue from our largest client in the industry dropped by nearly $190,000 in 2025. following regulatory changes that took into effect last year targeting this space. And that decline was immediate We are already absorbing the cost of policy shifts in this area and this bill would accelerate that dramatically I looked into it There is no legislation protection insurance I can buy for my business My company supports four employees and approximately 25 subcontractors. Thank you. Thank you for your testimony. Please proceed. Good evening, Madam Chairperson and committee members. My name is James Wolfe. I'm an attorney with the law firm of Stokes and Wolfe here in Colorado, which is a Colorado collection law firm I've been practicing for over 26 years. There's been a lot of testimony today in regards to the garnishment portion of this bill. And so I would just offer myself to answer any questions that you have about that. HB 191189 changed the garnishment statute, as Mr. Ali already testified. It increased the exemptions. Currently, the wage garnishment is 20% of an individual's take-home pay if they make over the Colorado minimum wage times 40% in a weekly cycle. So because it's tied to the Colorado minimum wage, it goes up every time the Colorado minimum wage goes up. It also, you know, a lot of testimony was about the garnishment being one of the last stance that you take. I would agree with that. We encourage voluntary payment arrangements. There's been a lot of testimony about voluntary payment arrangements, but even one of the proponents testified that when asked the question, what happened to the payment arrangement you were on, she said, I just couldn't afford to do it. so I stopped paying. Well, what happens when you stop paying voluntary payment arrangement? What is the enforcement mechanisms behind that? The enforcement mechanisms behind that are judgment execution proceedings. Those are the toolbox that this bill eliminates. The proponents and sponsors of the bill said, this bill does nothing to take away the enforcement mechanisms 100% when you get a judgment. That's just absolutely not true. If you default on a voluntary payment arrangement, enforcement mechanisms are wage garnishment, bank garnishments, liens on property. You currently can't foreclose on medical debt. And the exemptions for a lien on property is $250,000 of your equity in a home if you're under 60. 350,000 if you're over 60. So you get to keep that. But if you have that equity, you should have the duty to pay your medical debt. So thank you. I'm happy to answer any questions you have. Thank you so much for your testimony. Okay, we'll move online to Dr. Robinson. You. Chair Gildress, members of the committee, thank you for the opportunity to speak today. I'm Brigitte Robinson. I actively practice journal and trauma surgery, and I'm the president of the Colorado Medical Society. I want to acknowledge that the problem this bill is trying to solve is real. Colorado physicians see it every day, patients who can't afford the care they need, who delay treatment, who ration medications. Before a bill was ever generated, we already were working with patients on less expensive treatments, lower cost medications, and the only tests that are truly necessary. And when the Hill, this bill does do does come we build payment arrangements and absorb costs that are never recovered because the relationship matters more than the balance Medical debts puts real financial pressures on real people and it deserves a real solution Threatening patients with deportation to collect a medical debt is wrong. I don't know any physicians that support that. But this bill does not stop there. Under this bill, every physician practice in Colorado, every solo practitioner, Every rural clinic, every small group practice faces sweeping new restrictions with no recognition of the care already delivered in good faith. Most of us already voluntarily decrease payments when we can. Wage management is banned entirely for every patient at every income with no exception. Blanket account collections requires an attorney. Asset delivery across all patients, financial institutions, court judgment, and separate judicial order for typical unpaid balance. That isn't a process that costs more to debt than the debt itself. I'm sorry. It's not a good collection tool. Billing staff error, not misconduct. A documentation mistake triggers a minimum $3,000 in statutory damages plus attorney fees. That liability lands on every physician practice in the state. And the least of this bill adds a new unfunded screening mandate, preparing every practice to screen patients for Medicaid and public insurance programs. Thank you. Sorry. Thank you so much for your testimony. We'll move on to Dr. Hilty. Okay. I'm unmuted. Esteemed representatives, this has been a long day. I don't know how you hang in here. Thank you. I'm an emergency physician named Bill Hilty, working in an independent private group providing care at St. Mary's Regional Hospital in Grand John, Florida. I commend the bill for its intent to reign in abusive collection practices and to try to prevent some of the many really sad stories that we hear and have heard from patients today. But the bill is full of unintended consequences and is untenable for physicians and physician practices, particularly in Western Colorado. Both small and large clinics and hospitals, as you have heard, have very thin margins. Some days, only two days of cash reserve on hand for hospitals that send me patients here. and physicians are also struggling with reimbursement. I searched the internet and physician take-home pay is currently down to less than 10% of medical expenses in the U.S. overall. So this bill penalizes on at least a physician portion of it, the little guys, the frontline clinicians who are actually now one of the smallest costs in the system. One aspect of the bill imposes a fine of $3,000 for compliance failure. after an ER visit for which I get reimbursed on average before expenses less than $180. That's actually less than I paid a garage door repairman yesterday for 20 minutes of work. I'm now in my 32nd year of practicing emergency medicine. I've seen a lot. The job is truly complex and stressful, yet rewarding. I go to work every day because I care about patients. I care about their debt. But I need to actually have colleagues that actually get paid to keep seeing them and to help them with their medical issues. Do you want me and my physician colleagues to spend our time and energy with patients or spend it complying with more state regulations and figuring out how to sustainably get paid? This bill adds stress to already stressed physicians and will lead to more venture capital buyouts whose profit motivations actually make the problem you're trying to solve worse. If patients go bankrupt for medical debt, they can still come to emergency departments where I and my colleagues will provide care for them. Thank you. If physicians quit because of stress, burnout and financial unsustainability, then rural clinics and small hospitals close and Western Coloradans, as you have heard, lose reasonable health care access. Thank you. Thank you for your testimony. We'll move on to Michael Promeko. Good evening. Appreciate being able to speak. Thank you, Madam Chair and members of the committee. My name is Michael Promeko. I'm a family physician, also in Grand Junction down the street from where Bill Hilty is. I'm chief medical officer of primary care partners and a past president of the Colorado Medical Society about 15 years ago, when there were a whole lot more independent practices in the state of Colorado. I speak to you today to encourage you to oppose HB 1267. It's a bill that applies to all health care providers, not just UC Health. It's interesting and worth pointing out before I read the rest of my prepared statement that we are in a uniquely, it's a unique problem in the United States. Every year, over 600,000 people are going bankrupt because of medical issues. That doesn't happen in other countries. And I really sympathize and empathize with all the speakers tonight that are proponents of this bill. But it's the wrong tool to address an unfair health care system. I'm also wondering why independent practice is being thrown in with this bill. why small practices, independent practitioners all over the state of Colorado are being heaped in with a bill that is obviously addressed at hospitals, particularly urban hospitals. While I understand the reasons for the legislation, the consequences will only serve to make matters worse. The state, our country, continue to witness an ongoing relentless loss of independent practice. Vertical integration of previously independent practices is increasing the cost of care. Many practices under the strains of finances, quality reporting, changing payment models, and general burnout sell their practices to the nearest hospital or look to private equity to run their practice. It is well established that vertical integration raises total health care costs. While well-intentioned, the legislation will allow patients to ignore payments to providers at a time when clinics often wait a year for value-based payments to be processed and be paid. Please oppose this legislation to protect the remaining independent private practices here in Colorado and protect my patients by preserving our practice. I'd be happy to answer any questions about private practice and the ongoing forces that are closing doors around the state of Colorado and practices in your communities. Thank you for your testimony. We'll move on to Dr. Hill. Good evening, Madam Chair and committee. My name is Dr. Shannon Hill. I am a family physician for the last 19 years and have had, starting this July, I will be in Broomfield, Colorado for the last 13. My practice has been in place as a private practice since 1958. That is four years before Broomfield became a city. There are some unintended consequences that you haven't thought about. In the last five years half of the practices were once private are now owned by private equity or the hospital And that is now dwindled down to 15 percent of us on our side of town Most doctors are going to something called direct primary care. And I'll just be blunt about this. This means that the rich get care. And this will just become worse. See, my patients are incredibly loyal. They will drive past three hospitals to come in with a bleeding limb. This happens no less than three times a week. I'm not in an emergency room, so all bleeding is an emergency. So they come in, they're dressed immediately, they get their tetanus shot updated, and it's $200. Most of the time they've forgotten their purse, their shoes, their insurance card, and so we send them a bill. Do I hold their child hostage while somebody drives home to get their money? because that's what it will become to. I'll have to turn them away, which will lead them to an ER visit, which will be $15,000 versus my $200,000. So I ask you to please oppose this bill because I will have to deny care and ask for it up front before I treat a bleeding patient. Thank you for your testimony. We'll move on to Dr. Hughes. Dr. Hughes, can you hear us? Dr. Hughes? You are muted. I just got the message to unmute. Dr. Hughes, can you hear us? Okay, we'll give you a second. It doesn't seem like you can hear us. If you want to come off mute as soon as you can. In the meantime, let's open up for questions. Any questions for this panel? Okay. Dr. Hughes, we'll give you one more chance. Okay. Oh, unmuted. Does this work? Yes, you're good. Oh, hooray. it worked. My microphone on my laptop doesn't work anymore, so I have to use these earbuds. So you can hear me okay then? We can. Please proceed. Excellent. All right. Sorry about that. I'm actually on shift here in Telluride Medical Center, so thankfully I've got a moment to speak. Been kind of watching this all day long, and like Dr. Hilti said, I'm impressed of your guys' endurance for this long of a meeting. Anyway, I actually practice primarily in Durango, Colorado that's my my home base there and when I came there 22 years ago we were an independent group um we're doing the kind of group that basically you know was really deeply committed to the community for 30 years and um unfortunately because of poor reimbursement and inability to really uh be paid for the services we ended up being taken over by a private equity group a large contract medical group which really does not have any commitment to the community and we had no no For example, we don't have any ability to determine our shift coverage. And so it's all by making sure that people up on top get profits. And so that is what I think this bill would as I in opposition to because this bill would guarantee more and more groups would turn into large corporate medical groups because then they have to turn to private equity to fund them So I strongly oppose this bill, even though I completely agree and deeply saddened by the plight of many people that we should not have a system that is so broken where people have to choose between housing or food and their medical debt. debt. One of the things that I also work as a medical director for several ambulance agencies, EMS agencies here, and this bill would also get their ability to pay for services. And so already EMS is in a huge plight of being able to be able to pay the medics who make hardly any money. And now this would just ensure that you have more difficult time trying to hire them. So I urge you to let's let's work together to find a solution to our horrible health problems. But this is not the way to do it. And it would punish those who are trying to help the same people. Thank you. Thank you so much for your testimony. With that, we'll move on. Could you just I think we missed your name for the record, if you don't mind. Sure. James Wolfe. Thank you so much. OK. Thank you so much for your testimony and for sticking with us this late in the evening. I think we have one last opposition panel, so I think we'll do that and then move to our final support panels. So I'm going to call Alan Greenberg, Michaela Moody, Nicholas Prola, Mark Welter, Cecilia Comford-Arnez, Chris Skagen. Sean Cottrell. John Coughlin. And then if there's anyone else in the room who wishes to testify in opposition to the bill, if I have not called you, if you could come forward, please. And if we have any additional folks that are in opposition online, we can also bring them up. Thank you. Okay, thank you all so much for sticking with us for this long evening. I'm going to start from my left to my right. If you can introduce yourself, your organization that you represent, and you have two minutes, and you just have to push that tiny little button by the plug. Madam Chair, members of the community, my name is Michaela Moody, and I'm here as a licensed attorney and the legislative chair of the Colorado Creditors Bar. At the onset of this process, we were in an amend position, but now we ask you to join us in opposing this bill. Our concerns have always been focused on limiting judicial remedies, conflicting with existing state laws, the functional de facto ban on court access from medical providers, and the adverse economic impacts that will ultimately be borne by all Colorado residents. While I'm happy to talk about the law and procedures, which my colleagues have already discussed, the economic realities of this bill cannot be overlooked. Affordability is a problem in Colorado. Our residents can afford the 25 to 35 percent increase in insurance premiums which is exactly what happened in Delaware when it passed similar legislation a year ago Increasing premiums reduces the number of people that can maintain health and coverage. State programs can't afford to absorb those that lose their coverage. The state also does not have the dollars to allocate to debt buying like Delaware had to do in order to keep health care costs down. which still jumped another 10% despite Delaware being one of the most expensive healthcare treatments in the nation. Nor can our healthcare providers afford the expansion in uncompensated care. 26% of our hospitals already run at unsustainable levels. Without the dollars that can only be recovered through litigation because prior collection efforts have been unsuccessful, Many of these facilities and many more small providers will close their doors, limiting access to care for all of us. We agree with the sponsors that working class families need financial protections, which exist under current law. But we also agree with the sentiment that is echoed in the foundations of the Hippocratic Oath. First, do no harm. Today we ask you to do no harm by voting no on this bill. Thank you for your time today. I'm happy to answer questions. Thank you. Please proceed. Madam Chair, committee members, thank you for listening. Thank you for being here this late. My name is Nicholas Parola. I'm a shareholder at Bassford Remley, a law firm that represents medical creditors and financial institutions in compliance and defense litigation and defensive regulatory action. That includes hospitals, ancillary service providers, EMS and ambulance providers, collection agencies, first-party billers, and financial institutions that are not medical creditors as well. I think we all agree that medical creditors, collection agencies, billers should be liable to consumers and patients when harm is caused, when an error causes somebody to lose money, if somebody is at risk of losing their housing, if somebody is threatened. Those are all really important things and reasons to enforce the law. What I'm concerned about and what my clients are concerned about is what everybody else has called a fine up till now in this bill. And what really is a $3,000 private right of action that is strict liability and that has a fee shifting provision that awards attorney's fees. And it doesn't reward reasonable attorney's fees in this bill. It says all attorney's fees. They don't have to be reasonable. I'm an attorney. I think you should have reasonable attorney's fees, but there's lots of attorneys who don't. Fee-shifting statutes also usually turn into what I would call attorney cases, and those are cases where there is no harm, there's a technical error, it was a mistake, it was an honest mistake, it wasn't intentional, but there's litigation over it. And I think that's what this bill creates, is a great opportunity for attorneys to get rich. It's certainly good for my practice to have a bunch of these cases to defend. And that's okay when we're talking about a financial institution like a bank who has a bunch of profit to pay that money from or to pay damages from. But when we're talking about smaller providers and rural hospitals and things like that, settling these cases is not $3,000. It's $15,000 to $20,000 because of attorney's fees. Defending a claim that doesn't have merit isn't $3,000. It's $25,000 to $100,000. And I think that's not an intent of this bill, That's what this bill does. My clients would ask you to oppose this bill and not create a further reason for health care in Colorado to be unaffordable. Thank you. Thank you for your testimony. Please proceed. Thank you very much. Green button? No. It's the one right by the block. Green button. Thank you. I've done this before and seem to have forgotten. I'm grateful to the committee for this opportunity. I'm Alan Greenberg. I'm honored to serve as president of the Colorado Creditors Bar Association. I'm also grateful to an earlier witness, I believe Ms. Martinez, who said that wage garnishment could either be rare or essential, but not both. And I am grateful to her very much for crystallizing so perfectly our disagreement. I've been doing, excuse me, as a living for 37 years. This is what I do. I submit that wage garnishment is both rare and essential. We came to these committees, actually it wasn't this particular committee, but in the two or three previous legislative sessions. I'm very proud of our group that works with our legislative committee, including my law partner, Michaela Moody. And we fashioned remedies that made sense, that slowed down wage garnishment, reduced the amount to which there was exposure on wage garnishment for the consumer, and ended up with a livable solution. I don't believe that those have been given a full and fair opportunity to work. And now there's – at least we knew that as we reduced the amount that would be payable over in a garnishment and the amount that was exempt would increase, yet the incentive was still there. Wage garnishment was still wage garnishment. There was still a substantial reason to not only to deal with the payments, but to negotiate with our clients and my clients' clients. That will be gone. The other thing that I find rather onerous was this attack on the family purpose doctrines. Here it's 14.6.1.10. It's been called the claims against non-patients. It's long been Colorado's tradition and that in every other civilized country and state that I'm on the hook for my wife's medical bills. This would take that away in a way that's entirely inconsistent with the way we handle medical bills in general. Medicaid and Medicare eligibility are not based on income. They're based on family income. CRS 146101 criminalizes non-support and is specific about criminalizing non-support in the case of a spouse who's ill, sufferings from sickness. For those reasons, we're urging a no vote on 1270. Thank you so much for your testimony. Please proceed. Madam Chair and committee members, thank you for being here with us so late this evening. My name is Amy Cannaday, and I represent Credit Service Company out of Colorado Springs. Let me start by saying there are already strong consumer protections at both state and federal levels. We operate under strict compliance standards, and we work to help consumers understand the issue, identify options, and find workable solutions, while also helping providers of all sizes recover balances that can be paid. I want to be very clear about an important sector that this bill hurts, the small privately owned providers. These providers don't have massive balance sheets. They also don't have armies of compliance staff. They rely on lawful recovery of self-pay balances to keep their doors open. For many of them, unpaid balances and increased costs can and often do result in a reduction of services as you heard from several providers today The reality is healthcare is not free It costs money to provide services Providers already face enormous administrative burdens to comply with state and federal regulations and coordinating with third-party payer requirements. The rising cost of healthcare is not the fault of provider or the agencies that they use to aid in recovering balances. You've heard that litigation for past due balances is not used at high volumes, and that is true. But with medical debt no longer reported in Colorado, it remains one of the only effective ways to prompt engagement after months or even in some cases years of no response despite repeated outreach. You've also heard claims of threats of deportation, jail, or property seizures. I've been in this industry for 25 years, and I've never seen those tactics used or implied. That's not who we are. It's not what we do. And to be clear, any such conduct would be a direct violation of the FDCPA. The practical effect of this bill is not better consumer protection. The effect will be less accountability for those that can pay, more cost shifting to all of us, regardless of ability to pay, and more financial strain on all health care providers. For those reasons, I respectfully ask that you please not advance this bill. Thank you for your time and your service to Colorado. Thank you for your testimony. We'll move online to Dr. Sean Cottrell. All right. Can you hear me? Yes, we can. Oh, perfect. First of all, I'd like to thank you for your time also this evening. I know it's been a really long night for everyone. Your guys' endurance is impressive. I do understand also the intent of this bill. I think a lot of individuals tonight have had some very moving stories. After hearing all their testimonies, I would just say we all know our health care system is broken. One of the chair individuals in the beginning of this said, we understand the problem, but are we going about it the wrong way? And I don't remember the name of the person that said this, but I do worry that is the direction we're going with this. I'm a small, independent, private practice owner in eye care. I'm not a large hospital. I'm not UC Health. I know they said have the avalanche on their jersey or something. I'm not that. Private practice is fragile. I'm small. I don't have a huge staff that I can have a dedicated individual to worry about all the compliance and make sure we do everything perfect like this. And this would just add one more challenge. in Arvada we've already seen about three practices in the last six years go to private equity I'm seeing a lot of the families from those practices and it's really sad my colleagues that have retired and left those practices to private equity the the families are sad they love the doctors but the private equity is that they're all about the money and and this is the challenge with this bill is it puts me in the same pot as these large hospitals and all the panel individuals that are for this are talking about things that happen at major events. And in iCare, we can have some events, but not major events like this. So again, I would be opposed to this as it just puts us one more thing to be worried about, about not getting paid, not being able to pay for my staff, which is just not fair when everybody else can get paid for the services that they do. So I would just ask to say no for this. Appreciate the time. Thank you for your testimony. Can we move on to Cecilia Comerford My name is Cecilia Comerford and I the Executive Director of the Colorado Society of Eye Physicians and Surgeons I am going to read a statement on behalf of Dr. Rachel Rehm, who cannot be here now as she has been seeing patients today. Chair and members of the committee, I'm a pediatric ophthalmologist providing medical and surgical eye care for children and families, as well as adults with eye misalignment and outpatient clinics in Centennial, Wheat Ridge, Central Park, and Erie, Colorado. My practice also serves 14 hospitals in the greater Denver area from Castle Rock to Boulder. As a practice, 35% of our patients are Medicaid recipients, amounting to more than 10,000 patients per year. Timely access to care matters. Children cannot simply wait it out. I recall a 14-year-old girl who came to see me because her optometrist could not get her vision better with glasses. We discovered that she had bilateral cataracts and needed surgery. I referred her to her pediatrician for blood sugar testing as cataracts can indicate diabetes, which was confirmed. We postponed her surgery to manage her diabetes, and soon after cataract removal, I found she had severe diabetic retinopathy, a blinding eye condition. I referred her to a retina specialist who reported two weeks later that the retinopathy was almost gone. This was a patient who could have been completely blind without timely eye care. I want to acknowledge the goal behind HB 12-67. Medical debt is a real and serious issue for many families. Practices routinely work with patients to manage affordability. Unfortunately, HB 1267 is not the solution. For private practices already operating on narrow margins, this added risk threatens our viability, therefore threatening our patients' access to care. We already operate on such thin margins that a bill impacting our ability to collect on what could amount to enough of our gross revenue at any given time, it could potentially put us out of business. I respectfully urge the committee to vote no on HB 2612. 67. Thank you for your time and for considering the real-world impact this bill would have on children, families, and physicians' access to care in Colorado. Thank you so much for your testimony. We'll move on to Dr. Conklin. Thank you, Madam Chair, members of the committee. Actually, I'm John Conklin. I am an attorney. I'm outside counsel for the Colorado Medical Society. I want to raise some legal issues and points with this. As you've heard from others, There are many protections in Colorado law already for those who owe medical debt. There are notice requirements. There's requirements for not seeking collection within a period of time after insurance has been billed. There are limitations in terms of getting garnishment or other executions of judgment against somebody who owes medical debt, just like there is other medical debt. So those protections have existed way in the past, and then they were updated in 2023. My second point is that the bill would make medical providers the equivalent of collection agencies or bill collectors. And that is problematic in two ways. Number one, any time that the medical practice reached out to a patient after care was rendered in order to say, hey, you owe this amount or we have this balance on the bill, they would have to comply with the Fair Debt Collection Practices Act. And that is very onerous. They not used to that They not considered debt collectors currently but they would be under this bill And in practice they really would not be able to do that without notifying the patient and making the kinds of threats that this bill is really intended to prevent And so it has the unintended consequence of turning them into something they are not currently. Finally, I would point out that medical debt is involuntary. Nobody seeks to get injured or ill, but it is not the only type of involuntary debt. Everybody who's in a car accident incurs involuntary debt in some fashion, whether it's to a repair shop, their insurance company, subsequent insurance payments, whatever it is. I think there's a constitutionality issue with singling out medical debt for different treatment from other types of debt. you would be handcuffing medical providers and debt collectors from collecting on this type of debt in a way that they cannot in other debt. So we would urge a no vote for this bill. Thank you. Thank you so much. OK, any questions for this panel? Representative Wright. Thanks, Madam Chair. Two questions for two of our in-person folks. One question for you. Could you continue kind of educating me on what the current law is around incurring spouses or family members debt after they've passed on or whatnot? Sorry, what is your name again, sir? I'm Alan Greenberg. Mr. Greenberg. Go ahead. Thank you, Madam Chair. Apologies. This is primarily from – this is statutory CRS 146110, the Family Purpose Doctrine statute. It says that the debts of the family and for the care of the children are chargeable to the credit of both husband and wife or either of them. It's old language. It's an old statute. It is a ratification of the common law liability that spouses had between each other. That was, of course, in case when we accepted the common law in Colorado, two one two two four two one. but when we passed the married women's property act there was some question about do i still have a duty to support the answer is yes i absolutely have a duty to support i am delighted to announce that i am on the hook for mrs greenberg's medical bills and will continue to be so as long as she'll have now that is understood as being essentially a doctrine of necessity that i owe any reasonable necessary medical care for her as I would her food, clothing, other necessities of life. My two favorite cases on this, not that you asked, are the old Bowers versus Abrams. She comes back from breast cancer surgery and he's locked her out. He's not only not paying her medical bill, he's not giving her a place to live anymore because he's persuaded that her Kansas divorce was not final. Fortunately, Colorado Supreme Court disagreed. Reed versus Reed, a tragic case from the 40s where the mother shakes the baby until the baby stopped crying. That one was charged as attorney's fees to support an appeal from a murder verdict. Representative, I submit to you that that was not murder. that's manslaughter and in fact a successful appeal got that murder conviction reversed even after those two were separated and were no longer a couple Colorado Supreme Court said those attorney's fees to win that appeal are so closely connected to the marital relation that they are chargeable to the credit of both of you as of now we have have complete liability for each other's reasonable, necessary medical bills for a married couple. This bill would take that away and leave us I don't know where. I'd have to advise clients that, well, okay, I guess you don't have a family purpose doctrine anymore, but the old criminal statute for non-support is still out there, CRS 14-101. one, was the person involved here, what's the mens rea of that, negligently reckless or something like that, then you can call the DA. I'm pursuing restitution on an entire case of classes where the appropriate remedy and the current remedy and the remedy in all states that I know of, except Louisiana, different history, is a civil remedy, a civil claim for the medical bill for the spouse. I think I went a little long. Okay. Additional questions? Okay. Seeing none. Thank you so much for this panel. I appreciate you all hanging in here this late and your participation. Okay. We are going to move to what I think is maybe our last panel of opposition. let's call up Jacob Moore Alexandra Rakestraw Tracy Christian I'm sorry I meant support panel our final support panel sorry I apologize could those folks still come up they are all in support Christy Kibler Mary Colleen Casper Nick Torres Liz Lisbet Finseth True Apodaca Scott Loy and Mary Reich-Kenna If there's anyone else in the room that would like to testify in support, please come forward now and if there's anyone online, any additional folks online we've got everybody? Okay, great Wonderful, thank you so much for hanging in there this long You are a support panel, not an oppose. If you could, left to right, if you could introduce yourself, your organization, you have two minutes. Great. Good evening, Madam Chair and committee members. My name is Dr. Alexandra Rikstra. I'm an organizing member with Center for Health Progress and a family medicine doctor who currently works in an underserved clinic in Longmont, as well as ERs and hospitals throughout rural Colorado. I am here to testify in support of House Bill 26-1267. Because I work with a more heavily disadvantaged patient population, I routinely see patients who are forced to forego preventative care and important treatments because of the financial implications. My patients missed mammograms, blood work, colonoscopy, turn into serious hospital visits, and grave diagnoses. Just three weeks ago, I had to give a 52-year-old patient, a mom, wife, the diagnosis of stage four colon cancer because she couldn't previously afford to get a colonoscopy. And I know for a fact she actually a constituent of one of yours in the room tonight But you already know these stories especially after today testimony It no secret your constituents struggle to afford health care and that they are the collateral of our broken system Though they may work full time or two to three jobs often they still might get their car taken away because their child had an asthma attack. They might have their wages garnished on their money for rent that month because they had a stroke. And you will hear that the hospitals try to avoid sending patients to collections, and it's only a last-ditch effort. But at the end of the day, they need those recouped monies to pay their doctors like myself and other health care workers, even though tonight I've only heard one person give an actual stat on how much income they're getting in from that, and it was a soft data of 0.02%, I believe. But frankly, I'm furious that myself and my colleagues continue to be used as an excuse for my patients, especially the poorest of my patients being sued for seeking medical care. I am hard-pressed to find health care workers, not the hospital associations or debt collectors, health care workers who actually want our paychecks coming from patients who are getting sued. Other health care systems in our state and other states have also shown us that wage garnishing and suing patients in collections is not the way that it has to be. This is not a comprehensive health care reform bill. I would love to talk with all of you about that at a different time. Yes, we need to address vertical consolidation, grifty insurance companies that are the real root of the problem, but voting no will just continue to shift that blame onto the poorest of your constituents. I encourage you to vote yes on House Bill 1267. Thank you. Thank you so much for your testimony. Please proceed. Good evening, Madam Chair and members of the committee. My name is Marissa Halo, and I'm reading testimony on behalf of a community member tonight. My name is Tracy Christian, and I am here speaking as a resident of Aurora, Colorado, and a member of Center for Health Progress. I'm here to urge you to vote yes on House Bill 1267. I've had a long career in medical billing. I've worked in doctors, offices, and hospitals. I'm also in school, getting a major in health care management. My professional experience didn't protect me from experiencing medical debt because in our for-profit health care system, anyone can end up in debt at any time. I've also seen how the medical collection system is set up to prey on people. I've had my wages garnished before. When this happened, I never received notice about showing up in court because it was sent to an old address. That led to a default judgment, and I was garnished for over a year. During this year, it took a lot to keep a roof over my head for me and my family. More recently, I had an outstanding bill. Instead of offering a payment I could afford, a patient collections department told me to get a loan with Bank of Colorado at 10% interest. I learned the claim was never even submitted to my insurance, and the bank had to refund me for the mistake. Imagine I did not fight this. I would have paid money I didn't have on a loan I never needed, just to avoid a collection action. The rules are bent in favor of the debt collectors and the medical creditors, not made to protect hardworking people who are just trying to give their kids a good life. They treat us like a number and are financially incentivized to see us that way. I'm sick of hospitals and debt collectors scaring people into thinking they don't have rights and that we must find a way to pay, even if it means no gas in the car, no food on the table, or no medication for our illnesses. They hope we don't know how to fight back. Today we have a chance to put into place the protections we deserve and level the playing field I know that healthcare workers deserve to be paid for the services they provide but at what cost to the patient Nonprofit hospitals receive tax benefits to provide charity care, and they are financially protected for services they don't get paid for. Thank you. Thank you. Thank you so much for your testimony. We'll move online to Mary Reckrej Kena. Thank you, Madam Chairman and committee members. My name is Mary Rickanon, and I'm a member of Center for Health Progress. My story is largely about my parents and it is something from the past, but it's relevant to what's happening today. My parents owned a ranch in the foothills west of Pueblo. When my mom was dealing with cancer, my husband and I moved to Colorado from Chicago to help out and to spend time with her while she was still alive. We didn't know that faced with increasing medical bills and pressure and threats from debt collectors, my dad had taken out a bank loan with the ranch as collateral. as bills piled up and the interest rates went up higher and higher. Eventually, he couldn't keep up with the payments. So the bank foreclosed on the ranch, and we all had to move to town. My parents just to a one-bedroom apartment, including with mom in her very frail at that point condition. She died a year later. now this was 40 years ago my husband and i have rebuilt our lives and i don't think about it a whole lot but it was traumatic at the time and it really crushed my dad this strong kind man firmly grounded in his faith a survivor of the depression the dust bowl the invasion of normandy to lose everything that he had worked for and then to lose his wife after all they had been through. It killed his spirit. So your decision today won't change what happened 40 years ago, but it can protect other Colorado residents from things like this happening in the future. So I urge you to vote yes on HB 1267. Thank you. Thank you for your testimony. We'll move on to Mr. Apodaca. All right. Hello, Madam Chair, members of the committee. My name is True Apodaca. I'm the political director for SEIU Local 105. SEIU Local 105 represents over 8,000 essential workers across Colorado and unites a diverse group of essential workers across industries, including healthcare, professionals, janitors, security officers, and airport workers, all of whom play a critical role in keeping Colorado running. I'm here in strong support of SB 1267. 1267 draws clear lines around how medical debt can be collected. right now we are seeing practices that go far beyond just collecting a debt. These practices destabilize people's lives. Wage garnishment is one of the clearest examples. When someone gets sick and then loses part of their paycheck, it becomes harder to keep up with rent food and basic necessities It basically pushes people further into financial distress at the exact moment that they are trying to recover We seeing threats tied to immigration status used in debt collection, which is terrible. That kind of pressure has no place in health care. It creates fear and discourages people from seeking care when they need it, which harms individuals, families, and public health. And for many working people, losing a car can be just as devastating. A vehicle often is essential for getting to work, caring for family, and accessing health care. Go figure. Allowing medical debt collection to result in the loss of a car can take away someone's ability to earn a living as well. HB 1267 sets reasonable boundaries. It says that there should be limits on how medical debt is collected. This bill does not eliminate debt, but it ensures that collection practices do not push people deeper into crisis. Getting sick should not cost somebody their livelihood or their stability. SEIU asks you for your support on HB 1267. Thank you very much. Thank you so much for your testimony. We'll move on to Sandra Lamb. Good evening, Madam Chair and committee members. I'm Sandra Lamb testifying on behalf of AARP Colorado's over 670,000 members in strong support of House Bill 1267. Getting sick should not mean having your paycheck garnished or a lien placed on your home. Yet Colorado courts approve wage garnishment in an estimated 14,000 medical debt cases each year. AARP members, our neighbors over 50, often live on fixed incomes. A single hospitalization or cancer diagnosis is not a reckless financial decision. When creditors can garnish wages or drain bank accounts without warning, the result is a cascade of harms, missed rent, destroyed credit, anxiety that discourages people from seeking the health care they need. And this problem is about to get worse. The expiration of ACA and enhanced premium tax credits will cause approximately 225,000 Coloradans to lose or reduce their coverage. Federal Medicaid cuts could strip coverage from 378,000 more. HB 1267 addresses these harms. It bans wage garnishments for medical debt, limits bank garnishments, and codifies consumer protections that are notably relevant to older Coloradoans on fixed incomes. We've heard concerns about hospital sustainability, but patients ruined by medical debt, delay care and skip prescriptions, driving up costs for everyone. Protecting patients and sustaining providers are not mutually exclusive. AARP urges a yes vote on HB 1267. Thank you. Thank you for your testimony. We'll move on to Scott Loy. Good evening, Madam Chair and members of the committee. My name is Scott Loy, and I'm a Colorado resident, a husband, a father, and a paralegal, and I'm here to urge your support at House Bill 1267. During my first year of college, I was referred for an emergency procedure that required a spinal fusion. It was not something that I could have planned for or avoid. A few months after my surgery, I was barely able to walk and still in a back brace. I was unable to return to work while already being sent to collections by multiple providers involved in the operation. As it seems that there is a belief that folks have multiple off-ramps, this was I experienced. The only options I were given were minimum monthly payments across multiple providers. I was unable to make them all at once at age 20, but it did not stop me from trying. Those minimums added up quickly, leaving me with almost no room to negotiate what was affordable or realistic to resolve the amount. Then came the service of legal documents, and that's when I realized how serious the situation has become, as court hearings and wage garnishments were next. While recovering from this procedure, I had to navigate a predatory system and manage tens of thousands of dollars in debt without meaningful support, leaving the burden entirely on me. I completed the required credit counseling process to understand my options, but even after those steps, there was no realistic paths forward. Before filing for bankruptcy, I had more than $69,000 in outstanding debt and less than $700 in assets to my own name. This exact experience has also delayed my medical treatment to this day out of fear of facing the same financial consequences. The repercussions have left me unable to buy a home because of the medical bankruptcy on my record. One medical emergency has followed me for nearly a decade, limiting my ability to build stability and wealth for my family. This bill is about preventing that kind of long-term harm, and it places reasonable limits on collection actions, giving people time to recover before facing irreversible financial consequences. Surviving a medical emergency should not mean carrying a financial burden years afterwards. Please don't put companies over people, and I urge you to support this bill. Thank you for your time. Thank you so much for your testimony. Any questions from the committee? Okay. Seeing none. Representative Ryd. Thank you. For your wage garnishment, when was that? Yeah, so I actually filed bankruptcy. I'm sorry. Mr. Loy, let's start with Mr. Loy, and then what was your name? Marissa, reading on behalf of Tracy. Oh, then we'll move to Marissa, reading on behalf of Tracy. Mr. Loy. my apologies um yeah so i i actually was uh you know filing bankruptcy before i was able to get wage garnishment um ms marissa i'm i can't speak on behalf of tracy i'm unsure of when this occurred additional questions from the committee okay thank you so much for your testimony we appreciate you hanging with us so late okay with that um i will do one final call anyone online or in person who We'd like to testify. Okay, with that, witness testimony is closed. Sponsors, please rejoin us. We hear you have some amendments. Representative Mabry. Thank you, Madam Chair. We would request that somebody on the committee move L1. Vice Chair Leader, would you like to move? I move L1 to House Bill 261267. Wonderful. Representative Ray, sorry, seconded by Representative Ray. Representative Mayberry, would you like to describe the amendment? Yes, thank you, Madam Chair. Members, we described the changes in detail at the opening, but I do quickly just want to go what's left in the bill with the strike below. So in response to stakeholder feedback, I want to emphasize that we have stripped maybe 80, 90 percent of the provisions in the bill. And for us it is essential to maintain three key principles No wage garnishment your last and a lien on a home We are willing to continue to have conversations with stakeholders, with members of the committee, on the details of what remains in the strike below. But basically what is left is the wage garnishment piece, collection activities against people who are not patients, liens on primary residences, use of immigration status as a threat, seeking arrest or detention warrants with collection of a medical debt, and seizing, well, and we have an amendment that will lower the seizure amount. So we have an amendment to the amendment. So before the amendment is adopted, we want to move an amendment to the amendment. and there's the liability provisions that we talked about, the $3,000 and the statute of limitation at three years. And I was just going to ask for somebody to move L2. Yes, vice chair leader. I move L002 to L001. Second. Representative Frey, seconds. Representative Mayberry, would you like to describe the second amendment? Yeah, L2 to L1 is really simple. We're just bringing the bank account amount to the $5,000 that we've discussed throughout this committee. Okay. Any questions on either of these amendments from the committee? Seeing none, any objections to L2? Seeing none, L002 passes. Any objections to L001? Any objections to L001 as amended by L002? Seeing none, any objections to L001? L001 passes as amended. Okay, additional amendments from the sponsors? No additional amendments. Okay, any additional amendments from the committee? No. Seeing none, the amendment phase is closed. Sponsors, would you like to wrap up? Representative Joseph? Thank you, Madam Chair. Thank you, members of the committee. I want to start by thanking all the proponents who came and spoke on the bill and to all the witnesses who were here today. You've heard a lot of testimonies. I just wanted to respond to some of the conversation. Even though there were times that I stepped away from the room, I was still listening to most of the testimony as they were going through online. Some of the opponents of this bill have said that certain people refuse to pay their medical debt and that debt collectors do not target the working poor. Proponents have pointed out that medical debt is an equal opportunity burden because all of us get sick at some point. You've heard the story of community members who were left with $40,000 in medical debt. And you've also just heard about someone else who had closer to $60,000 worth of medical debt, while they only had a couple of thousand dollars in the bank. I can tell you that when I received collection notices, I had health insurance, which I believe I was paying over $300 a month for a healthy woman who rarely gets sick. After having an endoscopy and a colonoscopy, it was offensive to me to be nickel and dimed by medical debt here in Colorado. I was asked to pay here there and at another point We have passed numerous measures as you heard tonight to address these issues but they have not been enough to protect community members from wage garnishments lean on their properties or seizures of their personal belongings Wage garnishment is a particular harmful tool for the working class because it takes money directly out of their limited income, leaving them unable to pay rent, food, and other basic necessities. When people's wages are garnished or properties are seized, they cannot take care of themselves, and they end up relying on social services funded by the rest of the community. So when you hear opponents say that this bill will hurt providers, what they're really saying is that they would rather pass these costs on to the rest of us. This bill also asks that we do not allow the garnishment of the first $5,000 of someone's bank account. Yet, yes, this bill will not dismantle the health insurance industry. As you've heard testimony here today, people will still need health care, and I can confirm that personally. Even with insurance covering thousands of dollars, I still had to pay thousands of out-of-pockets. I'm deeply saddened by comments from opponents suggesting that they may instruct their medical doctor friends not to provide services to working people who cannot pay in cash. Health care is a human right. To deny someone care based on their ability to pay is a fundamental distortion of our humanity. Why would anyone want garnishments and liens on property as a tool of debt collection when it is the most marginalized who are impacted? I urge you to vote yes on 1267. A yes to protecting our most vulnerable community members and a yes to preserving human dignity and health care. And I wanted to note again, as you've heard from Representative Mabry today, we have done so much work. And most of the bulk of the work has been done by the coalition we've been working with. They've put in hours after hours working on this bill. 26-12-67 provide a detailed framework regulating medical debt collection in Colorado with the focus of protecting patients from aggressive and harmful collection practices. It broadens health care providers to include more licensed professionals and facilities, define medical debt clearly and adds patient as its protected individuals, expand medical creditor to include anyone trying to collect the debt, providers, collectors, debt buyers. More entities are covered, so more people collecting medical debt must follow these rules. The bill expands what counts as impermissible, extraordinary collections. The new prohibitions include threatening or taking someone's home or personal property, going after non-patients, threatening deportation or using immigration status as leverage, seeking arrest or jail over medical debt, garnishing of wages, taking money from retirement accounts, disability savings account, education savings account, seizing bank accounts below $5,000. This is about consumer protection. This bill offers, again, consumer protections for low-income individuals, immigrants, people with disabilities. you also heard about that the bill creates real consequences for violators A collection action is void if the collector violates the law The patient can recover up to $3,000 in their attorney's fees. and it also ends spousal liabilities for medical debt. I just want to say we all do this work because we care deeply about our communities. Some of the conversations that I hear today makes me really sad and I've shared that with you. because I know we all strive to protect our communities when we come here to the capital to fight for them. And I'm sure whatever vote you take today, you will be able to justify it. And maybe your communities may not even be aware that you take this vote today. But I hope you all consider the people who came before you and spoke. Those who told you about the medical debt, the crushing medical debt that they've dealt with. And at times, they probably felt like there was no way out. I'll stop right there and I ask you for a yes vote, for a yes vote for your constituents, whether you live in urban areas or in rural areas. Thank you. Representative Mabry. Thank you, Madam Chair. So members, I think it's important to be clear We know that this bill will not solve every issue in our broken health care system We need to do so much more But this bill will provide relief to our poorest neighbors We are not powerless We can listen to the impacted people who came here today to tell us that this is urgent We can listen to the labor unions, anti-poverty attorneys, consumer protection advocates Telling us to do this our constituents did not send us here to listen to debt collectors or to accept arguments that are not backed by evidence. Does anyone in this committee really believe that the people who came here today to support this bill are seeking to shield the wealthy from not paying their medical debts? Our neighbors came here today to advocate for people like them, people living paycheck to paycheck, single moms struggling to keep food on the table, roofs over their heads and roots in their communities. I find it offensive that some in the opposition claimed that this bill protects people who can pay. Debt collectors should not be the ones who decide who can pay. They should not be able to use the law to reach into somebody's wallet and tell them how to spend their money and how to take care of their families. People with means will still be covered by this bill. They have more than $5,000 in their accounts. They have second homes, stock options, cars, assets this bill doesn't touch. They have lawyers. They do not want to be dragged into court. They will not risk it. This bill does not eliminate consequences for non-payment. You can still be sued. Assets can be seized. Nothing in this bill requires debt collectors to disclose what is off the table. People will still settle because people, that is what people do when they get court paperwork. They get scared. They don't understand what is at stake. They settle. This bill preserves that. It preserves the lawsuit. Texas, South Carolina, North Carolina, Rhode Island, and Pennsylvania are not the upside down. They have functioning health care systems and they do not allow wage garnishment. for medical debt. Medical debt is not randomly distributed. It's more than twice as common in the lowest income households as the highest. Kaiser Family Foundation data shows 17% of the households earning under $35,000 were contacted by debt collectors for medical debt compared to fewer than 5% for households earning over $175,000. Over 80% of the medical debt is held by individuals with zero or negative worth. And we haven't even addressed the bills themselves. Up to 80% contain errors. 53% of adults with medical debt believe they've received an erroneous bill. And the CFPB estimates that inaccurate billing generates $88 billion in wrongful charges every year. You cannot argue people are refusing to pay valid debts when more than half of the people in debt believe rightly that their bill is wrong. Research from the University of Illinois confirms that medical debt does not reflect an unwillingness to pay. People do not choose to get sick. Let's be honest about who wage garnishment actually touches. It's not people with assets to restructure. And it is happening right now, even with the hospital discounted care program. The experts who advocate for consumers and people in poverty are here saying that program did not solve the problem. We would not be running this bill if it did. I made a TikTok about this bill last week, and more than 70 people commented on it, sharing their stories, things that happened to them recently. This bill is about the single mom working overnight, shift at a gas station, already taking out payday loans to buy diapers, who opens court paperwork and learns her next paycheck belongs to a collection agency. It's about the widow forced to sell her late husband's ring. It's about the family facing $250,000 in medical debt, $175,000 of it, caused by their provider's own billing failure who's now facing bankruptcy and the loss of their home because of the hospital's mistake. That is who this system pursues. And it's not because people won't pay. Because they show up to work and there is a paycheck to take. Now, let's consider who showed up in opposition to this bill. We heard from more debt collectors than providers. And I want to be clear about that. Actual medical providers who appeared here, most were in support. And opposition were mostly opposition were debt collectors and administrators. When this committee asked questions, the main question that mattered, how much of your operating budget defends on wage garnishment? We almost got no answer every single time. It was dodged. One provider admitted it was an incredibly tiny part of their budget. A rural provider said they've done it 10 times in five years for a total of 20 grand. 20 grand in five years. That is what we heard from the one rural provider that had any numbers to provide for us. UC Health can afford to put their name on the jersey of the Colorado Rapids, and the figure that they said was 0.02. And they're the biggest filer of lawsuits in this state. two hundreds of one percent. Meanwhile, a family loses their home. The opposition gave this committee two arguments, and both cannot be true. That wage garnishment is a last resort used almost never, and removing it would be catastrophic to their business model. Pick one. Because they cannot be rare and essential at the same time We have provided data from the Federal Reserve the Bureau of Economic Analysis the Kaiser Family Foundation the U Census Bureau The opposition offered generalities and assurance of lobbyists We should not vote based on unbacked claims. We should pass policy based on facts and data. Texas, North Carolina, South Carolina do not permit wage garnishment for consumer debts. A hospital can sue, win in court, hold a judgment, still cannot reach into a patient's paycheck. That's a state without Medicaid expansion, without the additional programs that we have here to help patients. Again, it's not our job to get the lobby to a place on neutrality on legislation that's designed to help the poor. It's our job to weigh the evidence and pass laws that make our neighbor's lives better. We've heard from those neighbors. We have the evidence. We have the model in Texas, North Carolina, South Carolina, and Pennsylvania. and those states are not the upside down. Let's get this done. Thank you for your patience. I'm very passionate about this bill. I wanted to fully address everything we heard, and I know my closing comments were long. I wasn't trying to be annoying. Thank you, sponsors. Vice Chair Leader, would you like to move the bill? Thank you, Madam Chair. I move House Bill 261267 as amended to the Committee of the Whole with a favorable recommendation. I saw two. I wasn't sure if she was seconding. Anyway, okay. I think Representative Mabry says this in his committee hearing. Closing comments from the committee, they're highly discouraged. Representative Ryan.
Thank you, Madam Chair. I learned a lot throughout the last couple weeks in trying to understand more about this process, certainly as a social worker myself, who work with a lot of people who are fragile. And dealing with debt is just one more thing that I think is hard and labor-intensive. So I think we're all in agreement that medical debt certainly is crippling for many, and I'm with you on that. I am not sure, though, that I agree that focusing on these specific pieces around wage garnishment and the bank amounts and the liens is actually solving, I think, the right problem of this systems issue. I'm going to know for today where I am movable later in the future. If you bring this back or want to continue to work on furthering protections for medical debt would be accountability for hospitals and providers that are making those errors. I think that was not addressed adequately, and I did appreciate some of the provisions there that tried to do that, but I think there's got to be more there in order to make sure we're not dragging these people through a hassle that's not their fault I also think the harassment of implied deportation I heard that from you representative Joseph heard it a little bit from I think one other person I didn't hear a ton other about that but that definitely is something that I don't think should be allowed in any way happy to see that written in statute so we can make that clear to the debt collectors I think the noticing process in general I am sad that you took that stuff out of the amended bill because I think there was something there. And of the folks who testified or were sharing stories of people that had testified, I think that was a compelling piece. For the ones that were more relevant recently within the last couple years, that still seems to be a problem, that there is a noticing issue in getting it to the right person, to folks still feeling like they are surprised when it gets to this escalated beyond 38 days or 120, whatever that date is. and then lastly that spousal liability piece that was something that I just learned about more today and I absolutely interested in severing that in future legislation Representative Stewart Thank you Madam Chair Thank you bill sponsors I do appreciate everyone that came out tonight to share their story their lived experience I certainly am empathetic and can very much relate. I was a teen mother. I think I'm still paying off medical debt from children. there are many parts of this bill that I really like and I very much agree with Representative Wright and if there's a way for us to bring forward legislation to protect immigration status that should never play a part in anything when it comes to debt collection or truly otherwise I did want to touch for a second on there's testimony regarding a duty to represent the most vulnerable and I absolutely agree. And when is it our duty to step in? But I would say as far as the district I represent, my vote today will reflect that, and this is not casting a vote for the folks in my district. I represent four rural hospitals. Three of them, I believe, are independent, too, for sure. One of those hospitals is Southwest Memorial, and they came out to testify tonight in opposition. Southwest Memorial is in Montezuma County, and it is the only hospital in Montezuma County, and the closest access to care for the Ute Mountain Ute Indian Tribe and Toyoc, which is where they are landed, their tribe is. And Southwest Memorial has, over the summer, we were really worried about some callback from Hick Puff, and I went to the mat for them because they are so integral to health care in Southwest Colorado. and to hear from them, I spoke to their CEO multiple times about this bill. I spoke to CHA, and the fears they have are very real, what's happening with H.R. 1, what's happening with the lack of the enhanced premium tax credit getting extended. We are facing catastrophic things, and you're right, we have an issue, but I don't know if I 100% agree with this policy and how to resolve this issue. I will be a respectful no for today, but that doesn't mean that my heart isn't with the goal here in protecting people. So I appreciate this conversation, and I thank you both.
Representative McCormick.
Thank you, Madam Chair. Thank you both for this bill. I intend to support today. I have questions around the banks and their being included in the definition of medical creditor. I was confused about that. and that the AG's opinion was the same, and so I want you all to revisit that. I also have concerns about the enforcement mechanism on page 4, lines 31 through 33, and how high that could potentially go as a penalty, especially for the smaller independent practices that could get scooped up in having to repay attorney's fees. I think if there's a way to target that, in some way to target that. after hours of listening to opponents and proponents, we heard from everyone how broken our health care system is, which only proves the point that we should all get behind a universal single stream health care payment system so that everyone can pay in to a system where they could afford and also that we could pay providers what they deserve and take away all of this headache and red tape and administrative costs So that all I have to say Representative Hamrick Thank you Madam Chair I want to thank the sponsors who have the best of intentions I want to thank all who testified. Hearing from patients who had to choose between care and financial ruin through no choice of their own is heartbreaking. It's the biggest reason for Vancouver City and America. I echo Rep. Ryden's comments about continued work on many of the concerns brought out today in Rhett McCormick's sort of vision for a better health care system. Speakers who support and oppose this bill both highlighted abusive collection practices, our predatory for-profit insurance system, and our broken health care system. However, I'm concerned that the small independent clinics are being heaped in with the big metro hospitals, that those small independent clinics are already struggling. Many are closing their doors. One testifier talked about half of their practices being taken over by private equity firms or hospitals. And looking at the seven laws that have passed over the five years, they've created some protections for consumers, but there's still so much to be done. However, I worry about the unintended consequences of this bill, the shuttering of clinics and patients' access to care. So I'll be a respectful no today.
Representative Johnson.
Thank you, Madam Chair. I would like to thank the sponsors. I absolutely agree we have a medical debt issue. There is something in that this has been something a passion of mine for years, having been on chemo treatments and having a ton of medical debt myself, without insurance, juggling multiple jobs trying to survive, looking at federal policy, state policy and former careers, being an EMS. This is something close to my heart. Last year, I tried to run a bill to do a study on where this is because we need to look at all of the issues and have the hospitals, the insurance, the patients, the debt collectors all in the room to talk. And I agree. In this building, we're not about making organizations and lobbyists happy, but our districts. And I will be forthright that as soon as I saw this bill, I took it right back to my hospitals. I took it to my patients. I took it to the debt collectors in my district. I took it to all the stakeholders, and I don't think this is the solution. There is an issue. I highly recognize that, and it is a passion that we need to figure out that gap. We need to make sure that, you know, patients aren't getting lost in the mix. Unfortunately, I will be a no today because I think this is going to cause more issues, and it would close some of my facilities, and while trying to fix a solution, we shouldn't be limiting the access that we have in the state. But I appreciate your passion. I would love continuing this conversation, but I will be a no.
Amal Winter.
Thank you, Madam Chair. We talk about representing our districts. One of the hospitals that spoke is in my district. And at the end of the day, you talk about the big Jersey hospitals. And what I've noticed is when you run the little ones out, they have to join the big Jersey hospital. And I can't see that happen in my district. I, the reason that I had that gentleman paint the picture that he painted in the questions I asked was to show the difference between the rural urban divide that we talk about and when the rural hospitals get up one after another after another, which they're representative of their communities. And I think that that's important. Rural Colorado is a little bit different. And they tried to paint that picture, what they do to take care of their communities, because we do more with less. And that's a fact. I don't think that this vote for me is political whatsoever. I'm doing exactly what you're trying to do, and that's represent my district. And I represent House District 47, but I represent rural Colorado. And like my other colleagues from rural Colorado, it was every region of the state saying this. They talked about Supreme Court cases that confused me a little bit. I'm new to this committee. I'm sitting in tonight, so I have a lot to learn, and I hope that you'll bear with me on that. There were some things that I wanted to ask questions about. I think that, you know, we're talking about taking care of people and people being able to afford things. But I can't be anybody but me, and I would be remiss if I didn't say that there's a lot of things that we do in this building that squeeze paychecks every day. And that has to be said. Because if we're talking about making things affordable, as we add fees and different things upon people, that takes that dollar, that $2, and those all add up to something at the end of the day. And I think that if I try to say this all the time, if we're really going to solve a problem, it has to be solving the problem. And it's about money in people's pockets. Sorry, I'm tired. It has to be about solving that problem all the way around and not picking and choosing if this $5 is okay to fee or tax somebody, but this $5 isn't. So my commitment is I've always made this commitment to everybody in this building. I'll work hard, and we may not always agree on how we get there, but I'll continue to work with you all. And there was just too much from the rural hospitals for me to essentially look at them at the end of the day and vote against them. So with that, I will be a no vote. But thank you for hearing me out. Thank you for understanding. I'm new to this committee, so thank you.
Representative English.
Thank you, Madam Chair. Can you hear me? We can. Okay, great. Thank you, everyone that came and testified, and it is late, and we're all still hanging on. But I just wanted to say, I do want to acknowledge all the hospitals and the small clinics that came in and testified. And it is very important that they're able to sustain themselves and keep their doors open at the same time. So the bill sponsors already said that this isn't a perfect fix. And I would acknowledge as well that there is some work that still needs to be done. And working people need to actually be able to take care of their families too and not be garnished in a way it would cause them hardship. So I want to acknowledge both working people and hospitals And there has to be a way that we can make it make sense for both sides So for today I will be a yes because I confident that the sponsors will continue the stakeholder and continue to work and have conversations to make the necessary changes So thank you.
Vice Chair Leader. Thank you, Madam Chair. sponsors I want to thank you for bringing this bill and to everybody who came in here and testified thank you so so much for your stories and the facts of what your lived experiences are I really appreciate that I have my own lived experience with my family it's not happening in 2019 it's not happening in 2021 it's not happening in 2023 it's not happening in 2024 only it's there's some that's been from 2024 25 this is 2026 and I'll tell you what there Johnny on the spot to send that collection right there after you sit there and you have challenged that you did not build that secondary oh you build the secondary at wrong you built the secondary as the primary you need to build the primary and then build it to the secondary can I back charge my hours that I spend on the phone countless hours trying to get this fixed. It's crazy, but yet they're just lagging around. They're not responding. Johnny on the spot to get BC collections on you and whoever else they send a text message to or an email. So I feel these people's pain. And this is ridiculous. My mother has to do this. She's 88 years old. Are you kidding me? I can't imagine all the seniors that are in my district going through this calendar. How many of them don't even know how to do all that? and to call and just give up. And then they're lost. So there's so much more work that needs to be done. I would love to work on a bill that's going to hold these people accountable for doing the billing correctly before they can send you to collections. I mean, it's just ludicrous what I see and hear from my own constituents, from my own family. Something needs to be done, and it needs to start with this bill. And it needs to happen today. So I take a look at this page. This is all the registered positions. Well I can tell you who got all the money by looking at these registered positions and how many are on here in a post position and who they represent Well I know who I representing because I know what side I on and I will be an absolute yes today Thank you Thank you, sponsors, for bringing the bill today. It was a robust policy discussion, I think, on both sides. It's always interesting to see that many folks come with all varying positions and just really appreciate how you both have really engaged in this process and really appreciate what I know so many folks, other members mentioned today, of all the folks that showed up. I was thinking earlier the amount of people that are here at 1030 in person for such an important issue, both oppose and support, and I think that goes to show how critically important the issue is And so really grateful for that. I kept thinking throughout the hearing about how deeply I believe that health care is a right and not a privilege. And I echo Representative McCormick's comments about wanting a different health care system in our country and not wanting folks to feel the burden of medical debt and what that all the stories that we heard. and we have to fix the larger problem. But I appreciate what this is trying to do for the folks that are burdened by the health care system in a way that would decimate their finances and create financial ruin. So I also appreciate the folks from hospitals and the providers and the debt collectors who engaged on this, who gave their perspective. I believe strongly that, especially in healthcare, stakeholders are all folks, and we need to listen to everyone. And I think that is why you're bringing a bill today that reflects that, and I really appreciate it, and holding true that we are representing the folks in our communities and making sure that everyone is protected. my inbox was filled half with support constituent support and half with against much like the hearing today so again I so appreciate your engagement I know you will continue to work on this and grateful that this is a possible solution to some relief for people that deserve that So I will be a yes today And with that Sure Can I I sorry Representative Luke Do you mind No Go ahead Thank you Sorry I going after you Yeah, there was just there was a lot of testimony and I appreciate all of it and I appreciate. The support and the opposition, and it's frustrating to sit up here and hear people bash one side. There were people that took the time to be here on both sides, people that took the time to wait the entire time, to wait for the delay and to testify. And I appreciate the business owners and the small business owners we heard from. It seems like some people are ignoring those. Very relevant testimony, trying to explain that regulation oftentimes is going to increase prices for someone. And there was much more that was relevant as well. But I do thank them, and I thank both sides. it's not easy to sit around and do this and take the time away from your work and whatever else you have in life. So just want to respect everyone that came and testified. I will be a no today, but I just wanted to get those words in that everyone takes the time to do this, and it's a lot, and I don't think we should be bashing anyone. Mr. Chudum, please call the roll.
Representative Zabodone?
No.
Bradfield?
No.
English?
Yes.
Frey.
Yes.
Amrick.
Baffelino.
Johnson.
No.
McCormick.
Yes.
Wrighton.
No.
Stewart.
Baffelino.
Winter.
No.
Wook.
No.
Leader.
Yes.
Madam Chair.
Yes.
The bill fails on a count of five to eight. Is there a motion to postpone the bill indefinitely?
I move to postpone the bill indefinitely.
Second.
Using reverse order.
Second.
Representative McCormick seconds. Okay. Are there objections to postponing the bill indefinitely?
No.
With no objections, the bill is postponed indefinitely. With that, the Health and Human Services Committee is adjourned. Thank you.