MINUTES OF THE SENATE COMMITTEE ON HUMAN RESOURCES AND FACILITIES Sixty-eighth Session May 31, 1995 The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:30 p.m., on Wednesday, May 31, 1995, in Room 226 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Senator Raymond D. Rawson, Chairman Senator Sue Lowden, Vice Chairman Senator Maurice Washington Senator Kathy M. Augustine Senator Joseph M. Neal, Jr. Senator Bob Coffin Senator Bernice Mathews GUEST LEGISLATORS PRESENT: Assemblyman Dennis Nolan STAFF MEMBERS PRESENT: Kerry Carroll Davis, Senior Research Analyst, Legislative Counsel Bureau Mary Gavin, Committee Secretary Linda Chapman, Committee Secretary OTHERS PRESENT: John W. Riggs, Sr., E. Clampus Vitus Robert Hadfield, Lobbyist, Executive Director, Nevada Association of Counties Denell A. Hahn, Director, Social Service, Clark County, Nevada May Shelton, Director, Washoe County Department of Social Services Carole A. Vilardo, Lobbyist, Nevada Taxpayers Association Diane S. Tavares, Director, Churchill County Welfare Gayle S. McCullough, Manager, Carson City Human Services Jon L. Sasser, Coordinator of Litigation & Training, Nevada Legal Services, Inc. Edrie Lavoie, Director, Lyon County Human Services Department Michael Torphy, Staff Attorney, Washoe County Legal Services Christopher P. Thompson, Chief, Health Care Financial Analysis Unit, Department of Human Resources The hearing was opened on Senate Bill (S.B.) 499. SENATE BILL 499: Authorizes conveyance of original Douglas County High School without charge or at a reduced charge. John W. Riggs, Sr., E. Clampus Vitus, testified in favor of giving the historic Douglas County High School to the Carson Valley Historical Society so it can be preserved and used. Mr. Riggs said in the past, Nevadans have let their historical information, buildings and artifacts get away from them, and these items can now be found in California and other places. Mr. Riggs suggested this transfer be without charge because the Carson Valley Historical Society is going to need all the money it can raise to restore the building. Senator Augustine asked if the school is no longer in use, and Mr. Riggs answered, "It is no longer occupied and will deteriorate if something is not done to preserve it and make it a useful historical building." The hearing was closed on S.B. 499 and opened on Senate Bill (S.B.) 514. SENATE BILL 514: Revises provisions governing provision of assistance to indigent persons by counties. Robert Hadfield, Lobbyist, Executive Director, Nevada Association of Counties (NACO), testified S.B. 514 is a measure designed to provide counties with the flexibility necessary to manage indigent health care and assistance programs to reflect local needs, as well as changing federal programs and unfunded state mandates. In effect, Mr. Hadfield said, S.B. 514 would allow counties to set local standards to address local concerns. In the absence of state funding for programs such as long-term care, counties must be given the flexibility to manage their resources. Mr. Hadfield continued, saying he understands there are those who have concerns regarding what counties may do when given this authority. However, Mr. Hadfield said he believes in these times when communities are demanding more services for their tax dollars, it is imperative local control is exercised over how revenues are prioritized and spent on indigent health care. Mr. Hadfield emphasized all agencies have the same goal of assisting needy residents to the best of their ability, and S.B. 514 is a critical step in achieving goals set by the counties. This bill is sponsored by the Nevada Association of Counties and is brought forward in concert with several other measures during this legislative session. NACO finds itself in the same difficult position the State of Nevada has alluded to in their budget workshops this year. Mr. Hadfield stated we are in changing times and must adapt to constantly changing policies at the federal level. The State of Nevada is continuously adjusting its policies to meet those. Yet, he said, NACO finds itself hampered by the same standards uniformly applied throughout the state which may or may not make sense in our local communities. Denell Hahn, Director, Clark County Social Service Department, testified in support of this bill from prepared text (Exhibit C), and explained the changes which were being requested and the reasons for them. Senator Augustine interrupted to ask about the changes in section 6, lines 26 through 32, specifically if these changes do not add the inclusion of transplants. Ms. Hahn replied affirmatively, saying Clark County is just not funded to carry responsibility beyond emergency medical care and cannot provide payment for procedures which Medicaid or Medicare consider experimental, investigative or of low success probability. Chairman Rawson asked if individuals have been successful in forcing Clark County to cover procedures not covered by Medicaid, and Ms. Hahn advised that they have not been successful in Clark County. Ms. Hahn then continued her presentation on the change in section 7, lines 4 through 23, adding, in Clark County they have developed a work program and offer employment to those persons who are employable. Ms. Hahn enumerated the changes requested in section 8, and completed her presentation. Chairman Rawson asked if Clark County was worried by having different standards in different counties, it might draw of flow of indigents from one county to another. Ms. Hahn said she does not believe people come to the counties for welfare benefits. Many times people with serious medical conditions will move to Reno or Las Vegas, not for the welfare benefits, but because that is where the medical services can be provided by bigger hospitals. Senator Augustine said she wanted to applaud Ms. Hahn for a new approach to this subject of additional funding for indigent care. Her only concern seems to be the counties need some guidelines as to what the new standard would be. Ms. Hahn said it is fairly typical, the department having the budget recommends what those standards should be. Senator Augustine asked if it is anticipated the figure of $438 given for one person living alone would fluctuate from county to county; that is, more in Clark County and less in Washoe County. Ms. Hahn said she thinks it will fluctuate because in Clark County, the department cost is at $750 for one person. May Shelton, Director, Washoe County Department of Social Services, said effective May 1, Washoe County is going to the current federal poverty guideline, which is $613 for one person. Ms. Hahn said it is all right because in Nevada's urban counties, many times people have longer waits for low-cost housing, many times there are different impacts which affect the families, and this allows the counties to tailor what their community is willing to fund and what their needs truly are. Senator Augustine said her concern is that some counties will go above the federal guidelines, which would be permissible. Ms. Hahn said all the counties have capped budgets, so they all have the same amount of money. If they spend it all on two people, there will be 200 individuals they do not serve, so that is part of the challenge. The counties know how much money is available and the number of clients they have to spend money on, so that governs the recommendation of what income levels will be. May Shelton testified from prepared text (Exhibit D) in support of S.B. 514. Chairman Rawson asked how they accounted for the low percentage of appointments that are accepted. Ms. Hahn said the clients have to wait about a week. If they are not seriously in need and do not want to go through this process, they just move on. Senator Augustine asked Ms. Shelton if it would be acceptable to amend the bill to say the payments will not exceed federal guidelines, or something to that effect. Ms. Shelton said she would not recommend an amendment. Because of the limited funds, it is not likely counties will exceed the federal poverty guidelines. Senator Augustine said if it is not likely, there should be no problem with the amendment because the federal guidelines could be exceeded in the future. Mr. Hadfield said long-term care is such a difficult problem for the counties. It is literally eating up all their resources and exceeding their ability to generate revenue. For that reason, he would say it is not likely to happen, and they would prefer not to place restrictions in the statues which have no force and effect. It would be redundant to do so. Furthermore, Mr. Hadfield said he believes part of the basic issue here is at what level these determinations should be made. He said since they are the provider of the service, those decisions should be made at the local level to reflect local conditions. In the unlikely instance a situation might occur and someone might wish to exceed the federal guidelines, it is local money and these are the people who know the local conditions. Ms. Hahn said, for example, if they were never to go above the federal poverty guidelines, which are at about $640 right now, those people in long-term care have a cost of care of $3,000- plus a month. If they were to eliminate people who have incomes of $640, but their cost of care is $3,000-plus, it would really not be practical for them to do so. Ms. Hahn continued by saying when you are talking about poverty guidelines, it is really a number and does not allow for people with no health insurance and some ongoing medical bills. If someone has income higher than the property level, but they are already paying $500 a month in oxygen and prescriptions, those are the kinds of flexible decisions we are asking the Legislature allow the counties to make. Senator Augustine said it seems to her if they are not going to exceed the poverty level, they seem to be adamantly opposed to it by eliminating all of the current guidelines on lines 37 through 46. She suggests that portion be left in statute, and said further she does realize they want county-by-county control, which she can understand, but her constituents are the taxpayers of these funds. If no limit is to be placed on the amount of money to be spent on indigent care in Clark County, Senator Augustine said she could not support this bill. Mr. Hadfield said that is the reason we have the long-term care. The State of Nevada set a limit in 1979 of $714, which has resulted in a $32-million program becoming a county responsibility. He said further, when you set limits like that, you often do nothing more than transfer the cost to someone else, and that is the reason local determination is favored. Mr. Hadfield said he did understand Senator Augustine's motivation, but often it creates other problems equally as bad and out of the control of the individuals who are capped. Senator Washington noted basically the result desired by this bill is some flexibility to be able to serve the needs of the indigent right away, based on current resources. Ms. Hahn replied, "That is correct." Senator Washington asked what is meant by lines 31 and 32 of page 2 of the bill. Ms. Shelton explained most insurance programs do not pay for investigative or experimental procedures, and Medicaid does not, either. Washoe County had a case in which legal services took the county to court, and the county settled out of court, but the judge said the court could not be more restrictive than the statute. Further, Ms. Shelton continued, Washoe County has guidelines and standards which are required by statute. They are filed with the secretary of state and approved by the county commissioners, but the judge was leaning the other way. The county attorney suggested perhaps the county should have language to protect it from having to pay for procedures for which its own insurance would not pay. Senator Washington said he understood what she was saying. Chairman Rawson asked what this language would do to health care providers. Ms. Shelton said since all the counties are currently at this standard or above it, this should have no immediate impact on health care providers. She said if a county wanted to really reduce their standard of needs, they have the opportunity to go to the county board and protest decisions. Since the county board has to figure out how to fund the programs, there is little likelihood this would happen. Senator Lowden said from the testimony, it appears the counties are bracing themselves for block grants, since this appears inevitable. Ms. Hahn remarked that on a federal level, both the republican and democratic proposals do allow for block grants, and it looks like those are going to pass. The counties are always the first line of response when new rules come in, and the counties want to be flexible enough to make sure there are not people in their counties who are truly in need who do not get taken care of, and the counties need to protect themselves against those they cannot provide for and it is a day-to-day balance. Carole A. Vilardo, Lobbyist, Nevada Taxpayers Association (NTA), testified in support of S.B. 514, saying last session NTA was before this committee. She understands the concern Senator Augustine raised, but looking at what NTA is trying to do at the local levels and the mandates put on them, the local governments have to receive some flexibility. This bill is an attempt to give them flexibility and allow them to maximize their dollars. She said one of the things she did not know until talking with a couple of the people within the social service area, is the state sets up the parameters, puts the excess down to local governments, and then the local governments have a problem trying to accommodate those needs within the budget. She continued by saying, just in the area of the type of services provided by social services, last session NTA found in Clark County, through the way they used their budget and in trying to service the most needy first, particularly those people with children, they were in the fortunate position of being able to provide assistance for a much longer period of time than Washoe County and the rural counties. This bill does nothing more than give the counties flexibility. Ms. Vilardo said the people, through Question 8, said they did not want mandates put down on local governments. This is what the Legislature has done and what this bill does is try to free up some of these restrictions which will better serve the taxpayers. There are different situations in every one of the cities and every one of the counties are not coterminus, and the elected officials there have to respond to the needs and prioritize. She stated the counties would all like to do everything for everybody, but there is not enough money to do this. She said by meeting every 2 years for 6 months, the Legislature can attempt to tell local government what and how they must respond to local views. The basic parameters can be set for the statewide policy, but there is a point the counties must acknowledge there is some responsibility in governing and spending the taxpayers' money. If the counties do it wrong, the legislators will hear about it and since they will be back in 2 years, the law can be changed. She said she believes the state is at a point where it needs to give the counties some flexibility and even review it in 2 years, and see what has happened once the reports are back. Senator Augustine remarked she was not disagreeing with the concept; the concept is excellent, and she does like the flexibility. She asks that the amendments do not exceed the federal guidelines. Ms. Vilardo responded by saying she thinks local governments should address that point. She advised she has met with local government officials and advised them not to go beyond the cap. She suggested some safeguards be put in to give the counties the opportunity to do what they say they will do. Chairman Rawson asked if she could foresee any fiscal effect on the state. Ms. Vilardo said she could not say there would or would not be. The long-term care issue involving what is paid on social services, who is eligible, who sets the eligibility is, from her perspective, a nightmare. Ms. Vilardo said she has a copy of the federal guidelines, and book is 1,116 pages long. Each federal program is a page long and tells what is mandated, what is granted and so forth. A person has to get the book to understand the program. There may be things the counties should be looking at, and there are probably things the counties should be refusing or substituting for something else. She stated she would bring the book in for the committee's review. Senator Washington said it seems the federal guidelines mandate certain situations must be complied with, as opposed to giving flexibility. Ms. Vilardo said through the 1970s and most of the 1980s, she wanted as many restrictions as possible put on local governments, and that is the way she testified. She has come to realize those restrictions do not work, and she now supports giving more flexibility to the local governments. Give local governments a 4-year sunset date, require some specific information back about the clientele ultimately serviced, how much they expended, how long they were on, and then make an evaluation. If local governments have those concerns and the constituents have been in contact and said they don't like what is going on, the response to the information local governments requested will give them the opportunity to turn around and reinstitute very specific guidelines, very stringent guidelines, and she will endeavor to support them. Senator Augustine said in response to Senator Washington's question, she was not referring to federal guidelines in the bill; she was talking about the monetary amounts in federal guidelines, and her concern was not to exceed the monetary amounts. Diane S. Tavares, Director, Churchill County Welfare, testified in support of the bill. Ms. Tavares said she is speaking as manager of an office in a rural county, where there is a small caseload, but also a very diversified group of people requesting services. She said the dollar amounts may be irrelevant in one case, and very important in another in terms of providing medical services for people waiting to get on Aid to Families with Dependent Children (AFDC), people being processed for food stamps but not yet approved, and she needs some flexibility in doing this. She would not propose to the county commissioners that any type of bill or program would go over the poverty level. Presently, there is a problem with long-term care and with housing in the rural areas. By taking the language out, the committee is giving them the freedom to manage their program by what the needs are in community, instead of being bound by a certain dollar amount for certain people. Gayle S. McCullough, Manager, Carson City Human Services (CCHS), testified CCHS does support S.B. 514. Jon L. Sasser, Coordinator of Litigation and Training, Nevada Legal Services, Inc., testified from prepared text (Exhibit E) and also remarked on some of the testimony presented during the course of this hearing. Mr. Sasser said poverty in this state is rising faster than in any other state in the United States. This situation has caused a great strain on the counties in terms of meeting the medical needs and cash assistance needs of this group, so the counties are in trouble. In terms of trying to get relief, they basically have only three places where they can turn; they can ask the Legislature to expand eligibility for the Medicaid program and, thus, relieve some of the burdens which presently fall on the counties. Taxes can be raised in the counties to the extent they can be within the cap, or they can cut services to the poor, which is what this bill purports to do. What has been described as flexibility, is a hole in the safety net. Right now, the counties are the stop of last resort in the safety net. A number of people are covered by federal programs, some by state and federal combined programs, some by state programs, and those who fall through the cracks have no other place to turn but to the counties. Since before 1900, Nevada has recognized a general ability to provide some assistance to the poor and has placed responsibility with the counties, and this provides for the first time to rip a hole in the safety net. Mr. Sasser addressed medical assistance, stating if a poor person goes to the emergency room at a hospital, under state law and under federal law, that person must be treated. Such treatment is not free, and the question is who pays the bill; is it the state through Medicaid, fifty cents on the dollar from the federal government or do county taxpayers pay it with no assistance from the federal government or, as this bill lowers guidelines, does it end up simply as a bad debt owed to the hospital. He stated bad debts are not free; they are passed along to the private paying patients and the insurance companies, and this drives their rates up. Mr. Sasser said 10 years or so has been spent struggling with hospital cost containment, and one of the biggest problems in the whole area is who deals with the cost of indigent care. If income guidelines are lowered for county medical assistance, it is being paid for somewhere, and where it will be paid for is in higher hospital rates passed along to a smaller and smaller pool. He said the question is not are those indigent costs going to be paid, but who is going to pay. Is it going to be a broad pool of all the taxpayers of the state with some federal assistance, is it going to be a narrow pool of county taxpayers, or is it going to be the narrowest pool of the sick. And, in essence, that is to whom this bill would propose to shift the burden. Further, Mr. Sasser said, the language sets the current income standard, which is proposed to be removed in section 6 and section 8, that came into existence in 1987 in a bill sponsored by Dr. Marvin Sedway. Mr. Sasser continued by saying the numbers seen in there are the 1986 federal poverty guidelines, and those eligibility standards have never been updated since 1986. In the last session of the Legislature, he said, there was a bill which did not pass which would have increased those to today's poverty guidelines. Instead, of some $434 per month for an individual, in 1994 it would be $613 a month. Instead of $150 a month for each extra person, it would be about $208. So the question is, is the state going to have more people qualify for the program, or less. If it is less, then the bill is paid by others. He asked, "Why do I care, as an advocate for the poor, as long as it is paid? The main reason I care is if the county program is restricted, the only access to health care my clients will have is at the emergency room, because they do not have access to the other medically necessary care the counties now cover." Mr. Sasser said, "My clients will have to wait until they are sick enough for the emergency room to take them. That is bad for their health, and it is also bad for whoever ends up paying the bill because it is the most expensive way to provide medical care to our citizens." Mr. Sasser referred to that portion of the bill which would restrict payment of general assistance and allow counties not to pay the same rates, or to exclude from eligibility those persons as being employable. He reminded the committee this is the fifth consecutive session of this Legislature in which Clark County has proposed this bill. It did pass the Senate last session, but did not make it in the Assembly. The basic issue here is that it is perfectly fair not to provide benefits to someone who is not willing to go out and try to get a job and become independent. Simply because somebody is labeled employable, does not mean that person is not making a best effort to get a job. Maybe there is a person who is 63 or 64 years of age, maybe a displaced homemaker who has not worked for a long time and does not have children. These people may be doing their very best and are still unable to obtain employment. The flexibility is already there. Ms. Hahn's department program requires these people to go out and make 30 job searches a month and requires them to engage in a public aid program which requires them to go out and work off their benefits providing community service. There are already mechanisms in place to basically filter out those who are not trying. He said he does not believe it necessary to put this change in the bill. Mr. Sasser said the third change, not paying for medical care which is deemed experimental by the Medicaid and Medicare programs, has saved peoples lives when they received such care. Mr. Sasser concluded his remarks by saying, "It is simply a question of who pays, and somebody will pay. There is no free lunch. The best way to handle this problem is not to add to the lines of the homeless by cutting back the general assistance program; nor to add to the lines in the emergency room, by tightening eligibility for county medical assistance." He said a better approach is contained in the bill which has not yet been heard and which is also sponsored by the counties, Senate Bill (S.B.) 471. This bill would provide some relief to the indigent in terms of nursing home care, putting more people under the Medicaid program so the federal government will pay part of the cost, and county taxpayers will not bear it all. SENATE BILL 471: Revises provisions governing eligibility for coverage for long-term care under state plan for assistance to medically indigent. Senator Augustine remarked she did not realize these provisions were put in the bill from the 1986 federal poverty guidelines. Edrie Lavoie, Director, Lyon County Human Services Department, testified in light of the current long-term care crisis, the department is desperate for a new approach, and on behalf of Lyon County, she requested the committee support S.B. 514. Michael Torphy, Staff Attorney, Washoe County Legal Services, spoke to the committee about Anna Zepeda, who is one of the individuals Mr. Sasser was talking about as having nowhere else to turn. Anna Zepeda is a 35-year-old mother of three children who resides in Reno. Her children are the ages of 7, 8 and 10. Last year, she was in need of a procedure called an autologous bone marrow transplant, which costs about $300,000. She did not have the money, and she did not have insurance. At point in time, she was eligible for Medicaid, but her procedure was not covered by insurance. Mr. Torphy stated part of the language which is in the bill on lines 31 and 32 of page 2, indicates the counties would be free from making payment on those procedures considered experimental by Medicaid or Medicare. This autologous bone marrow transplant procedure is not considered experimental within the medical community; it is considered experimental by Medicaid. He said Mrs. Zepeda's prognosis prior to the procedure was 9 months; her current prognosis is she will live about 10 years. A procedure which costs some $300,000, which comes out to about $10,000 per year for each of her children. "That figure," Mr. Torphy said, "if you are going to be really cold about the dollars, brings it right home. What is the value of a mother to a child, if it is not at least $10,000?" Mr. Torphy continued by saying the county, in its efforts to bring to bear on the problem of providing medical care to low- income individuals has brought it in a way which does not permit a process of any kind of rational consideration toward those who will be affected most by the decisions made. The process is short; the time period in duration is days; most of the decisions are made by individuals who do not have much knowledge of the people who would be most impacted by them. The specific language is often decided by telephone calls with the Legislative Counsel Bureau; the people of the State of Nevada are unaware of the issues relative to cost shifting and relative to shopping, which includes the flexibility. Mr. Torphy advised the State of California claims for 20 years people have been coming across the borders to access its health care system because of its very loose and somewhat disparate guidelines relative to eligibility. He stated, "If you are going to have flexibility, you are going to have disparate eligibility criteria, and you are going to have people moving between counties. If argument works on one side, it works on the other." Ms. Zepeda was very happy when ultimately she did receive the necessary care through the efforts of Ernie Nielsen, an attorney for Washoe Legal Services, who initiated a lawsuit on her behalf. Ms. Zepeda's prognosis prior to the procedure was several months. Mr. Torphy said he did not want to focus on the point there are individuals who survive because expensive care is provided to them. What he wants to draw the point to is how that decision is made. If it is going to be made in this form and this kind of a process, at the same time a decision is made about reform of the Medicaid services within the state, at the same time the federal government is considering drastically altering the Medicaid program throughout the country, he asked if there should not be time, if there should not be consideration given to what the impact is going to be on the very people the program is designed to aid. Chairman Rawson said he did not believe it is a mandated benefit in the insurance policies in Nevada, and asked if there are not private insurance companies that disallow transplants and, especially, the bone grafts. Mr. Torphy responded by saying with the specific procedure Ms. Zepeda received, there are plans which do provide for it and there are plans which do not provide for it. The status of this procedure is it is experimental. It is not considered experimental within the medical community. Chairman Rawson said the medical community has the advantage of not considering it experimental because it is so costly, and he does not know what the life expectancy is or what the success rate is for the procedure. Chairman Rawson cited the case of a heart transplant where the life expectancy is 7 to 10 years after the transplant, but the procedure can still be considered experimental from a Medicaid standpoint because there is a known failure rate with it. The chairman pointed out the fact that Oregon has done it a little more directly by simply compiling a list of medical conditions and letting the community decide which of these should be allowable under insurance and which should not be allowed. The chairman said it is interesting that the arguments Mr. Torphy puts forth would give the best care available to those cannot afford it, and is perhaps the desirable thing to do, but it has not yet been determined how this can be funded. Everyone is prioritizing procedures based on success rates, and that is what makes it hard to make those decisions. Senator Lowden added her insurance does not pay for many of the transplants. She feels there must be some criteria at some point. For one person, a procedure might be experimental; to another, it would not. Some guidelines, some rules must be followed. Senator Lowden said there are many people who have health insurance and who have had to live or die by these very strict rules. There are those who work and pay for health insurance, but their insurance would not cover the procedure received by Ms. Zepeda. Senator Neal referred to Ms. Zepeda's illness and asked Mr. Torphy if it was life threatening. Mr. Torphy said it was; she is suffering from breast cancer which has metastasized. Senator Neal asked if the objection is to the language on page 2, lines 31 and 32? Mr. Torphy said his point was not to make a specific alteration in the language chosen by the county, but rather to point out these choices are made on an ad hoc basis, which is basically the way this will end up because the input is so small. He said, when you consider the changes are coming relative to health care across the country and relative to health care within the State of Nevada, to provide local flexibility is irrational. He said it does not lend itself to the very values addressed of rationing care. Washoe Legal Services, as well as other advocates of the poor and the disabled, have, for years, been forced to fight on an individualized basis relative to health care, rather than engaging in the process on a broad base. Senator Neal asked if "medically necessary" is a phrase used in the federal statute of Medicaid and Medicare. Mr. Torphy said it was; Medicaid and Medicare provide for a larger definition than S.B. 514 does. The definition in S.B. 514 is somewhat narrower. Senator Neal asked further if the determination would be left to whoever administers this program in the counties. Mr. Torphy answered affirmatively. The chairman noted if the county sets a standard and tries to spread it over the number of people they think they are going to have so their money is basically used up, could a person not argue that is more fair than proceeding on a "first come, first served" until the money is used. It is an attempt to spread it out over as many individuals as possible. Mr. Torphy responded by pointing out the Medicaid debate relative to the reform and the waiver request. The whole idea of the debate is the establishment of some rational basis of weeding out care which is either inappropriate or not cost effective. This process does not provide at all for, in fact encourages, the exact thing just mentioned; which is, the "first come, first served" basis. Specifically, the county's value is going to be to dump the dollars as fast as possible so they can stop administering the program. Senator Mathews said this is absolutely not true in Washoe County. Mr. Torphy said he is not saying that is what presently happens; he is saying this is the value this bill would encourage. Senator Washington said he knows it is not true. Mr. Torphy repeated what he said is not what the counties presently do, but it is the value the bill would encourage. A bureaucracy has values independent from the people within it. Senator Augustine asked Mr. Hadfield if he was aware of Assembly Concurrent Resolution (A.C.R. 21), saying if the committee passes this bill, does it have a negative impact on S.B. 514? ASSEMBLY CONCURRENT RESOLUTION 21: Directs development of proposal to amend state plan for assistance to medically indigent to include coverage for treatment of substance abuse provided to recipient of Medicaid in nonhospital setting. Mr. Hadfield said although he did not feel qualified to speak to the question, his initial reaction is it does not have a negative impact. Senator Augustine said she feels S.B. 514 would not be needed because it would be redundant. Ms. Shelton said she would like to address Senator Augustine's concern about setting a ceiling on the income level. In Washoe County, the department serves some 350 to 400 people in long- term care who are not covered strictly by state Medicaid money. These people might have incomes of $800 a month or $900 a month, but their cost of care might be $2,500 a month, so their income is first applied as a patient liability to their cost of care, and then the department picks up the difference. She said if a ceiling is set, these people would not be eligible for the department's program, and the long-term care homes would not maintain them if someone were not paying for the rest of their cost of care. That is one of the reasons the department would ask the committee not to put a ceiling on income. Senator Washington said he has no problems with S.B. 514. SENATOR WASHINGTON MOVED TO DO PASS SENATE BILL 514. SENATOR LOWDEN SECONDED THE MOTION. Senator Neal said if this bill goes forward, considering some of the things that are in it and the vagueness of the wording, it is going to wind up in court, and the committee will be back here next session dealing with it. He said this is not the first time this bill has been discussed, and there are still some of the same problems attendant to it. He said he understands what the counties want to do, but most of the content of the bill is vague, and it will end up as a legal matter. In fact, he said, the reason this bill came to the committee is because there was a legal problem in Clark County, so this legal problem has not been solved. Senator Neal said he believes the committee is proposing to put something into statute which is going to give the Legislature some problems, particularly dealing with section 7, which seems to be the heart of this particular piece of legislation. Income limits and potential sources and things like that will give everyone problems. He suggested some attempt be made to try to iron things out while it is before the committee. Senator Mathews said she does support S.B. 514, and since it has been before the committee three times, there has been ample time to work out the problems. Senator Augustine asked Ms. Shelton if the Department of Social Services already has guidelines, and what is being done with a person making $800 a month now. Ms. Shelton said the current guidelines are the bottom level of $438; it is not a ceiling, so their income guidelines have to be at least $438. Senator Augustine said it reads: "...whose income is less than $438.00..." Ms. Shelton said, "That is right, but you are proposing a ceiling of not more than the poverty guidelines, which would severely restrict the department's abilities for people in long-term care. That is her concern." Senator Augustine said she likes the concept of the bill and would vote for it in its current form, but does not quite understand it. She will check out the federal guidelines before it goes to the floor. THE MOTION PASSED. (SENATOR NEAL VOTED NO.) * * * * * Chairman Rawson asked if the counties would like to start some public dialogue, such as Oregon did, in spelling out some of the procedures which are approved and acceptable to the community. He thinks this is something that needs to be done on the public level versus this level, and the committee would be happy to hear the public dialogue and work with them. The hearing was closed on S.B. 514 and opened on Senate Bill (S.B.) 88. SENATE BILL 88: Requires school districts to establish programs providing bilingual education. SENATOR AUGUSTINE MOVED TO DO PASS S.B. 88 AS AMENDED. The chairman said the amendment was in section 1, and it changes the word "shall" to "may" in line 3, so it reads: "The board of trustees of each school district may..." Senator Augustine said she sees this bill does nothing except make Nevada meet federal guidelines, and it is needed. Chairman Rawson said there is a motion to amend and do pass on this bill. Senator Augustine said she objects to the proposed amendment because it goes above and beyond federal guidelines. She supports the bill the way the committee amended it and passed it out of committee on March 29. Chairman Rawson said the committee would report it to the floor the way it is. Senator Lowden said everyone seems to like the original amendment. The chairman said it would be reported that way. Chairman Rawson said he understands the State Department of Education's concern about "may," but it seems to be the way the committee likes it. The motion on S.B. 88 died for lack of a second. The hearing was closed on S.B. 88 and opened on Senate Bill (S.B.) 363. SENATE BILL 363: Exempts certain facilities for care of adults from payment of fees related to licensure. The chairman asked if the committee wants to take these kinds of adult day care facilities and exempt them from licensure fees. The chairman asked if the state department had any concerns and if they support the bill? Ms. Davis, Senior Research Analyst, Legislative Counsel Bureau, said they testified in support and no one testified in opposition to the bill. The chairman pointed out these are nonprofit day care facilities, and it is probably an unnecessary expense for them. Senator Augustine asked what kind of fees the bill would exempt them from and the amounts. Ms. Davis said the fiscal note shows the loss of revenue from not imposing those fees on those facilities to be about $6,300 a year. Senator Augustine asked if the facilities know their budget is going to be less by $6,300? Ms. Davis answered affirmatively. SENATOR MATHEWS MOVED TO DO PASS S.B. 363. SENATOR LOWDEN SECONDED THE MOTION. THE MOTION CARRIED UNANIMOUSLY. * * * * * The hearing was opened on Assembly Bill (A.B.) 105 ASSEMBLY BILL 105: Requires school district to provide instruction relating to violent and other crimes. Ms. Davis advised that Assemblyman Nolan testified he would prefer the bill be processed in its first reprint form, not the second reprint, so he would like to have the second amendment stripped out and go back to the first amendment. Senator Augustine asked Assemblyman Nolan if he knew that since this was a ways and means committee amendment, it must go back to that committee for them to concur if this committee takes the second amendment out. Assemblyman Nolan said he did not realize that, but the first reprint had passed ways and means the first time. It was referred to both the ways and means and education committees. The amendment passed the education committee in its original form, then it was referred to ways and means and passed that committee in the first reprint. Senator Augustine said the ways and means committee put the amendment on the bill, so this bill would have go back to the ways and means committee for them to concur, if this committee takes the amendment off and puts the bill back to its original form. Assemblyman Nolan said it was actually amended on the floor and received passage off the floor. Chairman Rawson said this may be an issue that the conference committee can deal with, and we will let them do that. Senator Neal remarked that the second reprint of this bill allows for elective courses in the eleventh or twelfth grades. The bill, as it was introduced and also the first reprint, seems to suggest that the these shall be mandatory courses to be included in the existing course of the study of government. He said it seems to him that time is being taken away from the actual teaching of government to include this, which creates a time problem to be considered. He continued by saying, it appears the Assembly, in order to get around this, has made this an elective course so students could elect to take these particular courses. Chairman Rawson said it was his impression that the sponsor of the bill is saying that the types of crimes and penalties therefor are an important part of government curriculum and should be included. The bill is saying that no government course is complete without considering crime and punishment. Assemblyman Nolan said that is, in essence, what the bill is intended to say. Also, within the mandated curriculum under American government, there is a provision for crime and its effects on the individual to be taught. It does not provide for the penalties for committing those crimes. By including this under American government, there is already a mandated curriculum. This bill just falls in and allows the teaching of penalties and also, as an elective, the teaching of psychological and physiological effects of crime, if that is desired. Mr. Nolan continued by saying if it was put into drivers' education, where it creates a brand new, completely elective course, a curriculum would have to be developed for this course, which would have a fiscal tag, and there is no place in drivers' education to accommodate this. He said, in effect, what the second reprint of the amendment does is (1) it creates a whole new elective curriculum, and (2) it requires expansion of the drivers' education curriculum. This actually affects two different curriculums. Chairman Rawson asked if this was an attempt to just kill the bill by amending it? Mr. Nolan said no. The proponent of the amendment was the only one who objected in ways and means, and it narrowly passed by one vote. Senator Augustine asked if the first reprint was done in the ways and means committee, and the second reprint was added on the floor of the Assembly. Mr. Nolan responded affirmatively. Senator Augustine then asked if her understanding was correct that Mr. Nolan wanted to go back to the first reprint of the bill. Mr. Nolan again responded affirmatively, explaining that the first reprint was brought out by the education committee and the Classroom Teachers Association. Senator Augustine said she did not have a problem with the first reprint, other than the wording where it says the state board "shall" by regulation versus the state board "may" by regulation be required to be included in the existing course of study. Mr. Nolan said he thought that would defeat the purpose of the bill. His intent is to get those individuals who this might have some effect on and act as a deterrent by teaching juveniles not only what the laws are, but the penalty for breaking those laws. If the bill makes it permissive, this defeats the intent of the bill. Senator Mathews said she thinks it is late to talk about changing some behaviors in the eleventh grade. By that time, they are pretty well set. She feels this would be more effective in a social studies class at an earlier age. Mr. Nolan advised it was started in a social studies class, but education says it does not belong there. SENATOR COFFIN MOVED TO AMEND TO THE FIRST REPRINT AND DO PASS A.B.105. SENATOR NEAL SECONDED THE MOTION. THE MOTION CARRIED UNANIMOUSLY. * * * * * Senator Augustine said she still wants the bill to be permissive instead of mandatory. SENATOR AUGUSTINE MOVED THAT "SHALL" BE REPLACED BY "MAY" ON THE FIRST LINE 3 OF THE FIRST REPRINT OF A.B. 105. SENATOR LOWDEN SECONDED THE MOTION. Mr. Nolan said this bill does require the school districts to develop a curriculum, but nowhere in there does it say how expensive or how limited that curriculum has to be. In essence, it really limits the mandate to practically nothing. If the school district wants to spend 10 minutes on this particular subject, that is all they have to do. Chairman Rawson said, in fact, they have a curriculum now, and Mr. Nolan answered affirmatively. Further, Mr. Nolan said, the Nevada District Attorneys Association has volunteered to help the school districts in developing anything they wanted along these lines, so it is already permissive. Senator Augustine advised it is not the school district being mandated under the bill; it is the state board the bill is mandating. Mr. Nolan replied the state board is to require the individual school districts to develop the curriculum. The state board does not have to; the school districts would have to, and they can develop it to whatever degree they want. It is really not a time-hour mandate. They can do as much as they wish to meet the particular school district curriculum. Senator Augustine asked if Mary Peterson of the State Board of Education has testified on this bill. Mr. Nolan said he did not know if Ms. Peterson testified in this matter, but a school representative did sign off on the final amendment. Senator Coffin pointed out the bill has passed the committee. To additionally amend the bill would require that the committee rescind the previous action. Chairman Rawson agreed. Senator Augustine said she was going to amend the motion, and the chairman advised her to wait and pass the first motion to go back to the first reprint, and then amend. Chairman Rawson advised Mr. Nolan that the committee will not object to his running the amendment on the floor because of the technical aspects of how the committee passed this bill. The motion to amend the bill was not voted on. The hearing was closed on A.B. 105 and opened on Assembly Bill (A.B.) 36. ASSEMBLY BILL 36: Revises provisions governing inspection of certain records in state archives. Chairman Rawson advised some material has been provided to Senator Coffin and Senator Neal on the way Oregon looks at this aspect of government records. Senator Coffin said he does not have the concern he had at the time of the hearing. After reading the information from Oregon, he thinks Nevada is handling this properly. SENATOR LOWDEN MOVED TO DO PASS A.B. 36. SENATOR MATHEWS SECONDED THE MOTION. THE MOTION PASSED UNANIMOUSLY. * * * * * The hearing was opened on Assembly Bill (A.B.) 330. ASSEMBLY BILL 330: Extends date for prospective expiration of provisions that limit increase in charges that major hospitals may impose. Chairman Rawson advised that there is a clarification on page 8 of the work session documents (Exhibit F). Ms. Davis said that Senator Neal had raised some questions during the hearing and had asked the Department of Human Resources to respond, and the department has now responded. Chairman Rawson asked Christopher P. Thompson, Chief, Health Care Financial Analysis Unit, Department of Human Resources, if there is anything further he wants to introduce on this bill. Mr. Thompson said there was not. SENATOR MATHEWS MOVED TO DO PASS A.B. 330. SENATOR AUGUSTINE SECONDED THE MOTION. THE MOTION CARRIED UNANIMOUSLY. * * * * * There being no further business, the meeting adjourned at 3:15 p.m. RESPECTFULLY SUBMITTED: ____________________________ ___ Mary Gavin, Committee Secretary APPROVED BY: _____________________________________ Senator Raymond D. Rawson, Chairman DATE:________________________________ Senate Committee on Human Resources and Facilities May 31, 1995 Page