MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session January 30, 1995 The Committee on Health and Human Services was called to order at 1:15 p.m., on Monday, January 30, 1995, Chairman Jan Monaghan presiding in Room 330 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Mrs. Vivian L. Freeman, Chairman Mrs. Jan Monaghan, Chairman Mrs. Jan Evans, Vice Chairman Dr. William Z. (Bill) Harrington, Vice Chairman Mrs. Deanna Braunlin Mrs. Barbara E. Buckley Ms. Saundra (Sandi) Krenzer Mr. Dennis Nolan Mrs. Dianne Steel Mr. Wendell P. Williams COMMITTEE MEMBERS ABSENT: None GUEST LEGISLATORS PRESENT: None STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Prinicpal Research Analyst OTHERS PRESENT: Yvonne Sylva, Admin., Health Division, Dept. Of Human Resources Myla Florence, Welfare Admin., Welfare Division, Dept. Of Human Resources Dr. Donald Kwalick, State Health Officer Luana Ritch, State Health Division Bob McCune, Health Management Associates Rita Hambleton, American Association of Retired Persons Audrey Brooks, American Association of Retired Persons Sharon Ezell, Bureau of Licensure/Certification, Health Division Judith Wright, Bureau of Family Health Services Jan Gilbert, League of Women Voters A. F. DiSalvo, Health Division Will Scott, Health Division April Townley, Welfare/Medicaid Rebecca Ward, Budget Jim Riggs, Budget Margaret J. Morgan, Retired Public Employees Assoc. Of Calif. Patty Smith, Nevada Auto Body Assoc. Bill Moell, Vital Statistics, Health Division Ron Lange, Health Division A committee introduction requested by the Department of Human Resources Health Division was presented. Bill Draft Request 40-852 makes various changes to existing regulations and transfers some duties from the State Board of Health to the Department of Human Resources. ASSEMBLYMAN FREEMAN MOVED TO INTRODUCE B.D.R. 40-852. ASSEMBLYMAN KRENZER SECONDED THE MOTION. THE MOTION CARRIED UNANIMOUSLY. Agency presentations began with Yvonne Sylva, Administrator of the Health Division, who introduced Dr. Donald Kwalick, State Health Officer. Dr. Kwalick supplied a handout, (Exhibit C,) which gave a thumbnail sketch of the role of public health in a health care system. He defined "public health" as organized federal, state and local systems of community wide, population based services that impact on the public at large, rather than specific medical care to individuals in the community, per se. Activities of the public health department were enumerated and explained in detail. Some of them include prevention, licensing, inspection, testing in schools, chronic disease control, immunization, home visits, environmental protection, health education and promotion. Several videos of public service announcements (PSA's) were viewed. The subjects of the PSA's ranged from prenatal care and child immunizations to radon awareness, AIDS (acquired immune deficiency syndrome) and cigarette smoking. Ms. Sylva presented the committee with a packet of information, (Exhibit D,) which included the text of her speech, a listing of bureau chiefs, location of division offices and an organizational chart of the health division. A booklet entitled "Nevada's Framework for Public Health", (Exhibit E,) outlines the common vision and direction for public health activities and was prepared as a joint effort between the Health Division and Clark and Washoe County Health Districts. Also included was another booklet entitled "Nevada's Safe Drinking Water Program", (Exhibit F,) which Ms. Sylva encouraged the committee members to peruse. Ms. Sylva also invited the committee members to tour the Las Vegas Special Children's Clinic between February 6 and 17 while the Legislature is meeting in Las Vegas. Assemblyman Evans noted the state does not put any money into the Women, Infants and Children's (WIC) program and wondered what might occur if the federal funding is either reduced or cut off. Ms. Sylva responded that they are currently reviewing all the proposals that might be placed before Congress. The National Governors Association is proposing consolidation into eighteen nutrition block grants. This would probably result in WIC being a looser. Mrs. Evans asked, if 25 percent of the department's 44 million dollar budget came from the state's general fund, then is the balance from the federal government or some other source? Ms. Sylva responded of the remaining 75 percent about 22 percent is from fees and the balance is from the federal government. Mrs. Evans asked if the 25 percent funding by Nevada is representative of our sister states. Ms. Sylva stated the percentage going into public health is small and varies from state to state. The majority of funding goes into after-the-fact; public health generally does not receive a large percentage. Mrs. Evans, feeling Nevada's percentage is very low, requested figures from other states at Ms. Sylva's convenience. It was generally agreed among the committee members and Ms. Sylva that WIC will be sacrificed if money is scarce and allocation of funds is left up to the states. Assemblyman Freeman asked about the accuracy of the radon home test kits. Stan Marshall, supervisor of the radiological health section answered the question for Ms. Sylva. He stated that the commercially available products have met the Environmental Protection Agency (EPA) criteria. The results one will get from the kits are valid plus or minus 25 percent of the indicated value. Mrs. Freeman asked if he was comfortable with that. Mr. Marshall responded that he is comfortable because that measurement is a starting point for a person to evaluate appropriate mitigation. Mrs. Freeman asked if there are any clean water proposals this session. Ms. Sylva responded there was an interim committee that looked at issues related to water and several proposals directly tied in with Nevada's safe drinking water program have come out of that committee. They have a full time equivalent (FTE) associated with expanded services in the state laboratory to ensure testing is timely and accurate, and also FTE's outside the laboratory included in their budget. Additionally, the Division of Environmental Protection and other agencies are requesting FTE's. Mrs. Freeman asked whether the "Apple Project", which provides education, training and support to high risk adolescent girls to prevent teen pregnancy needs to be expanded. Ms. Sylva responded that no one single program is the answer, however it has been very effective. Dr. Kwalick added additional information about the program and said it is being evaluated now as it just started within the last year and a half. After it is evaluated and can be better justified, they may ask the next legislative session for more money. The program gets $25,000 statewide per year. The program is in three or four sites. Basically, adolescents are paid not to get pregnant. They have a contract. If they live up to it they get paid. They also participate on an ongoing basis with leadership enhancement. Assemblyman Nolan asked whether they handle complaints on Health Maintenance Organizations (HMO's). Ms. Sylva said they do if the complaint has to do with availability, accessability or quality. They also work in a cooperative effort with the Division of Insurance. Mr. Nolan also asked whether they have any oversight on Managed Care Organizations (MCO's) or other organizations that provide health care related services. Ms. Sylva said they do not specifically, however, if there is anyone providing a service in Nevada and they receive a complaint, they would ensure that the complaint is followed up on. Assemblyman Harrington asked about plans for this session to limit the health problems related to alcohol and tobacco. Dr. Kwalick said the Nevada State Medical Association and the Coalition for Tobacco Control are going to be presenting either an omnibus bill or several bills to decrease tobacco use in public places, to decrease or prohibit vending machine accessability to youth, to really try and prevent our youth from starting to use tobacco. That is the thrust of most of the bills he can recall. Dr. Harrington then asked if there was any hope of getting tobacco out of grocery stores; making those products be sold in separate stores. Dr. Kwalick responded that the whole issue of licensure of tobacco purveyors is up in the air and no bill has been introduced, but if Dr. Harrington wanted to introduce one, that would be great. Mrs. Evans asked about the PSA's. She only recognized one of them. Luana Ritch, Public Health Education and Information Officer for the Health Division, explained some are currently in use and some were run in past campaigns. PSA's run at the discretion of the television stations. Since deregulation of the communications industry, PSA's are no longer required to run and as a result we now get a wide variety of coverage and penetration. Many times they run during very early morning hours. A new public agency strategy emerging is leveraged purchase of air time. This involves a public agency purchasing air time through a cooperative such as with the Nevada Broadcast Association. For each single purchase spot, they obtain one or more donated spots from their membership of broadcasters. Sometimes the agency can get a match of air time as great as five to one, so for every spot they buy, and often those are prime time spots, they can get up to five spots for the price of one. This is a very effective public information technique many agencies are starting to use. All the PSA's to date have been run gratis. The Health Division has never used any of its funds. Mrs. Freeman asked Dr. Kwalick about the possibility of increased federal funding to focus on teen pregnancy. He said all the funding is up in the air at this time. Assemblyman Krenzer congratulated Ms. Sylva on the success of the "Baby Your Baby" public service announcement program. It is a great example of private/public partnership in an effort to curb a severe public health problem. Myla Florence, Administrator of the State Welfare Division, began the final agency presentation. An overview of the Division's programs, (Exhibit G,) was expanded upon during Ms. Florence's prepared speech, (Exhibit H.) With all the talk of welfare reform, the division's mission statement was very important and took several months of revisions. The statement reflects not only their accountability to taxpayers but their sensitivity to the clients they serve and the challenges the staff faces in delivering services in a fast growing state. (Exhibit I,) the table entitled "Program/Category Caseload and Expenditure Growth" shows just how great this growth has been and what is projected in the future. About 50 percent of the people who apply for assistance are denied, so beyond the caseload increase is an incredible increase in the number of applicants. Eleven major goals to initiate in 1994 , (Exhibit J,) and which are continuing on today were also identified. During the past biennium the division has been working with the Department of Employment, Training and Rehabilitation, Nevada Business Services and Nevada Partners in enabling more low income people to obtain employment. Ms. Florence mentioned the MGM in Las Vegas where over one thousand low income people were placed in employment, about 75 percent of whom remain employed, with wages ranging from $6.50 an hour to $13.00 per hour. These are not just minimum wage jobs. The MGM did work very well with the division in trying to find meaningful employment for individuals who are now no longer on welfare rolls--which is their objective. Mrs. Freeman mentioned wages in northern Nevada are not as high, $5.00 an hour was mentioned, and asked Ms. Florence if she felt the difference in wages paid would make any difference if a program like the MGM's was initiated in the north. Ms. Florence stated her employment and training staff are currently working with representatives of the industry up here, particularly as related to Silver Legacy, however they have not proposed any salary range. From September, 1993 through late spring of 1994, the Welfare Division facilitated a task force around the issue of welfare reform. Included as members were representatives of various state agencies, local agencies, advocacy groups, and employment organizations. The task force met many times during the 15 months and attempted to devise a plan to meet Nevada's needs. That plan has been incorporated in the agency budget request and includes expanded employment and training activities as well as providing social workers in the large urban offices to provide more intensive case management for families in trouble. It also envisions providing more time for front line eligibility staff to talk with individuals as they come into the system about "what brought you here", and "what we can do as an agency to help you get on your feet again in the quickest amount of time possible". The functions of front line eligibility workers have been added onto over the last 30 years to the extent that they are almost robotics in their interaction with clients. Paperwork and regulations have so overburdened the workers that the person to person aspect has been taken out of the picture. The notion of agency service should be reintroduced so as to ensure eligibility determinations are made appropriately; while also being sensitive that the goal is to work with people to move out of the system. In an effort to inform state legislators and the congressional delegation, as well as other agencies interested in welfare issues, of the status of the programs and what their direction is, an agency newsletter has been initiated. Another innovation has been the opening of a third food stamp issuance outlet in Las Vegas by Boulder Highway and Tropicana which is serving approximately 6,000 individuals from eastern Las Vegas as well as the Henderson area who no longer have to travel across the Las Vegas Valley. Improvements in the Medicaid program, including implementation of a bus system to reduce costs, and additional staffing added to the Maternal Obstetrical Medical Services (MOMS) program were highlighted. Also addressed is the fact that approximately one-third of the individuals who apply for public assistance benefits in Nevada are making application to receive assistance with health care. In the absence of a national plan, Ms. Florence would like to see Nevada design its own universal health care program. Ms. Florence presented a status report on managed care for Medicaid recipients. She explained they are continuing to work with an actuary to complete the cost- benefit section of a waiver they are drafting for submission to the feds. There are a number of other issues associated with managed care, but the division has data capacity issues to resolve and that is why the implementation date for managed care is recommended to be January, 1996 as opposed to July, 1995. The area of welfare reform was also touched on by Ms. Florence. Welfare reform is not just looking at welfare offices. In order to have meaningful reform it must be looked at very broadly in terms of education, parenting and a whole host of other social issues associated with the system we have currently created. The welfare budget addresses some of those things but not everything. As an example, there are some enhancements in the education budget that have some impact on welfare as a way of life. Family resource centers that will also contribute to the solution of families in trouble and long term welfare recipients are being proposed. Another major issue confronting the division is NOMADS (Nevada Operations Multi-Automated Data Systems). NOMADS is a fully integrated data system incorporating all of the division's eligibility functions which includes AFDC (Aid to Families with Dependent Children) , food stamps, Medicaid, etc. along with child support enforcement functions, child care, block grant issues and employment and training. Nevada is the only state in the nation to attempt to design this system. The major beneficiary of the system will be the client in that there will a single point of contact in most cases for clients. They will see one eligibility worker who can determine eligibility for any program they may be applying for. They will not have to make several trips back to the welfare division office with verifications. Ms. Florence sees tremendous implications to the people who will be served as well as, hopefully, reducing some of the paperwork previously mentioned with the eligibility workers. Legislation the division has proposed for the upcoming session, (Exhibit K,) was presented next. Bill draft requests fall in the areas of child support enforcement, Medicaid (with regard to meeting 1993 requirements relative to the liability for third person payments), Medicaid Estate Recovery program, and a food stamp bill that is a housekeeping issue requested by the federal government. Mr. Nolan asked what the ceiling income for welfare recipients is. Ms. Florence said that is a difficult question to answer because some types of income are disregarded. It also depends on the household size and whether it is food stamps or AFDC because the thresholds vary. Eligibility criteria for each program differs and some things are allowed for one type of assistance and not allowed for another. Mr. Nolan said he counted 18 different programs and asked whether it was possible for an applicant to be on several of those programs, i.e. food stamps, child assistance, health care, all the way through. Ms. Florence responded that it was. Assemblyman Steel stated one of the concerns of the people in her district was welfare and asked whether the expenditures listed in the charts on (Exhibit I) under the different categories included the money spent for staffing and administration. Ms. Florence responded that within the charts it is just payments or services to clients. Within Medicaid, the overall administration costs are three percent of the total budget. Ms. Steel asked whether the 50 percent of applicants who are denied were not qualified or was there no money to help them? Ms. Florence responded that the most often cited reason for denial is lack of cooperation, which may be caused by the client or may be a result of the rules which specify the length of time a client has to get verifications or information to the agency. What she could not say is how many people who are denied ultimately come back and are finally approved. Ms. Steel then asked whether fraud was a prevalent problem within the Welfare Division and also if they had any sister programs with other states surrounding Nevada to track down people who are getting double assistance from both states. Apparently Ms. Steel had been informed that this does occur on a regular basis. Ms. Florence responded that there is a fraud investigations and recovery unit within the Welfare Division, but it is not as large as the caseload would demand. There are eleven investigators statewide for 95,000 food stamp cases, 13,000 AFDC cases and 85,000 Medicaid recipients. What they have done is look at utilizing the resources they do have most efficiently. As eligibility workers are processing new applications, if they suspect that there may be some fraud or abuse going on, then that person is referred to the investigators before getting onto assistance. As part of the investigation process they have the ability to link with a federal clearing house to check for food stamp double dipping. If someone has reported living in another state, and it is suspected they may have been on assistance, then that may result in contact withthe other state. In AFDC there is a 1.4 million dollar projected cost benefit from identification of program violators. People were either required to pay back, over time, what they had received, or there may have been actual grant reductions to those individuals. Investigations do reap benefits and Ms. Florence wishes they could do more. Chairman Monaghan asked about the job fair held in Las Vegas within the last two months. Apparently it had been poorly attended and many businesses were disappointed not to have been invited to participate. Ms. Florence said that her agency was a participant and not the organizer. Chairman Monaghan then asked about managed care. It came out of the 1993 session and was to be ready to start this January and now is delayed. She wants to know what happened. Ms. Florence stated during the 1993 session the division had submitted a waiver to the federal agency, the Health Care Financing Administration, for implementation of the managed care program to begin October, 1993. During the course of the session the legislature, through Senate Bill 559, put a hold on that track and indicated it wanted the department and the division to work with the interim committee in structuring a program to begin this July,1995. There were numerous meetings between the Department of Human Resources staff along with the Interim Committee on Health Care to look at how that program should be designed. Chairman Monaghan then asked whether the waiver could be sent off while the program is being designed or whether part of designing the program has to be included in the waiver that is sent off. Ms. Florence said the program design does need to be fully defined in the waiver application for it tells who you are going to serve, what kind of services you are going to provide, what kinds of costs you anticipate and what the cost benefit would be. They must ensure the federal government that they will not spend more under the waiver than they would without it. Chairman Monaghan asked whether the program is still being put together. Ms. Florence said that it is not all together. It is fairly well defined. The largest piece of missing information at this time is cost analysis for which they have contracted with an actuarial firm to provide the best expenditure data and analysis they can put together. Chairman Monaghan then asked how to prevent this session doing something to the project so that a new project and a new waiver must be sent off again. Ms. Florence replied that it depends on what the legislative debate this session results in. It was very frustrating to her staff to finalize a project, send it to the feds with the understanding they were going to implement a program, and then have it postponed. With no further questions, the meeting was adjourned at 3:15 p.m. RESPECTFULLY SUBMITTED: Terry Horgan, Committee Secretary APPROVED BY: Assemblyman Vivian L. Freeman, Chairman Assemblyman Jan Monaghan, Chairman Assembly Committee on Health and Human Services January 30, 1995 Page