MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-Second Session
March 31, 2003
The Committee on Health and Human Serviceswas called to order at 1:00 p.m., on Monday, March 31, 2003. Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada, and, via simultaneous videoconference, in Room 4406 of the Grant Sawyer State Office Building, Las Vegas, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairwoman
Ms. Kathy McClain, Vice Chairwoman
Mrs. Sharron Angle
Mr. Joe Hardy
Mr. William Horne
Ms. Sheila Leslie
Mr. Garn Mabey
Ms. Peggy Pierce
Ms. Valerie Weber
Mr. Wendell P. Williams
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
Assemblyman David Parks, District No. 41
Assemblyman Rod Sherer, District No. 36
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Terry Horgan, Committee Secretary
OTHERS PRESENT:
Anne Cory, President, United Way of Northern Nevada and the Sierra
Mary Liveratti, Deputy Director, Department of Human Resources
Linda Lera-Randle El, Straight From the Streets
Connie Myer, Straight From the Streets
Mark Nichols, Executive Director, National Association of Social Workers, Nevada Chapter
Patricia Martinelli Price, Executive Director, Pulidor Foundation
Anthony Mosely, God In Me Ministry
Brother David Buer, Order of Franciscan Monks, Poverello House,
Las Vegas
Eseta Kaufusi, SageWind
Jacob Davis, SageWind
Elizabeth Dorway, Board Representative, Jubilee Center, Carson City
Jean Roberts, Jubilee Center, Carson City
Michael Stoops, Director of Community Organizing, National Coalition for the Homeless
James Vilt, Nevada Disability Advocacy and Law Center
Mark Armerding, M.D., Nevada Psychiatric Association
Pat Coward, GlaxoSmithKline
Tom Wood, Wyeth Pharmaceuticals
John Kimbrough, Account Director, State Government Affairs, GlaxoSmithKline
Charles Duarte, Administrator, Division of Health Care Financing and Policy, Department of Human Resources
Mary Wherry, Deputy Administrator, Division of Health Care Financing and Policy, Department of Human Resources
Ruth Paxton, R.N., National Alliance of Mental Illness
Rachael Paxton, R.N., National Alliance of Mental Illness
Roy Barraclough, Project Development Officer, Rural Health Management Corporation
Mary Griffith, Health Resource Analyst, Bureau of Health Planning and Statistics, State Health Division
Robin Keith, President, Nevada Rural Hospital Partners; President, Nevada Rural Hospital Partners Foundation
Nancy Ford, Administrator, Department of Human Resources Welfare Division
Leslie Danihel, Chief, Eligibility and Payments, Department of Human Resources Welfare Division
Jan Gilbert, Progressive Leadership Alliance of Nevada
Chairwoman Koivisto introduced Assemblyman Parks, sponsor of A.B. 259.
Assembly Bill 259: Creates Advisory Committee on Homelessness. (BDR 38-752)
Assemblyman David Parks, District No. 41, explained that A.B. 259 was a bill that would create an advisory committee on homelessness. As background, he noted that approximately 18 months ago, Nevada had been selected as one of eight states to participate in a Policy Academy dealing with homelessness in families with children. The Policy Academy met monthly; Mr. Parks was the Assembly representative to the Policy Academy, and Senator Ray Rawson was the Senate representative. Mr. Parks stated that A.B. 259 would take the work that the Policy Academy had completed to date and establish an Advisory Committee with 19 specific individuals who would serve on it. He observed that there were people from many governmental agencies constantly working with homeless issues as well as many people outside government, so the overall intent of the Committee had been to assemble those people and to work more effectively to see that the programs being individually dealt with could be combined to bring about a satisfactory result.
Mr. Parks pointed out that the bill requested $10,000 to cover some of the Committee’s expenses. Teleconferencing had worked out well, he commented, but eventually the people needed to sit down together in a meeting. No Committee members would receive salaries for their services, he added, but some travel expenses would be paid for with the money.
Anne Cory, President, Chief Professional Officer, United Way of Northern Nevada and the Sierra, Vice Chair, Policy Academy, pointed out that the Policy Academy had accomplished a great deal with very few resources and continued to meet and coordinate homeless services being provided in the northern, southern, and rural areas of Nevada. Ms. Cory stated that the Advisory Committee attempted to go beyond local service provision to look at policy-level issues that facilitated the provision of services at the local level. She indicated there were serious problems with homelessness in Nevada and that many of the homeless were families with children. She emphasized the importance of giving the Committee official standing by creating an Advisory Committee on Homelessness that would allow for fund-raising so it could undertake projects requiring resources not available from state or local governments. Official status would enable the Committee to write grants and look for funding from other sources, Ms. Cory reiterated. The Committee also hoped to do extensive public information campaigns and various other activities that would further the group’s goals of making Nevadans aware of homelessness and the services offered, and make those services more available to the people who needed them.
Chairwoman Koivisto remarked that it sounded as though the Advisory Committee had accomplished a lot.
Ms. Cory agreed that the Committee had been successful. She added that an inventory of existing assets, those programs and services currently in place in Nevada, had been compiled. In addition, the Committee had worked very hard to coordinate the various care groups that applied to the federal Department of Housing and Urban Development (HUD) for funding together.
Assemblywoman Leslie, referring to Sections 8 and 9 of A.B. 259, which spoke of gifts, grants, requests, and donations, asked if those were references to federal money or HUD money, and she also asked what the role of the Advisory Committee would be in deciding how those funds were distributed.
Ms. Cory answered that those provisions in the bill had been developed specifically because the Committee had been planning a public information campaign on homelessness throughout Nevada. The intent had been to inform those people who were at risk of becoming homeless about the resources available to them. For people not at risk of becoming homeless, the campaign had been intended to address some of the stigma associated with homelessness. Ms. Cory said that in planning the campaign, it had become evident that the Committee needed the ability to apply for corporate or foundation funding. She added that the Committee did not anticipate applying for federal funding and had no intention of supplanting any current grantees. Ms. Cory explained that the idea was not to look for direct service provision funding but instead to look for funding for the kinds of activities that could supplement and support service providers.
Ms. Leslie asked if Ms. Cory really wanted to put those funds in the state treasury.
Ms. Cory replied that she was not certain what the options were, unless they were to declare a fiscal agent. Because of the number of agencies involved in the Policy Academy team, it would be very political to designate one of the agencies as fiscal agent. The idea was to create access to funding from private sources and use it for projects supporting policy-level activities.
Assemblywoman Leslie explained that sometimes it was difficult to get the state to respond, particularly if the money was needed in a hurry.
Assemblywoman Pierce observed that no one on the Advisory Committee represented veterans, and added that it had been her understanding that many veterans were amongst the homeless.
Ms. Cory agreed that there were a number of veterans among the homeless in Nevada. She explained that in discussions about the makeup of the Advisory Committee, the possible list of people to include had become so lengthy it was not possible to include all groups. Ms. Cory indicated that there was excellent representation on the Committee from veterans’ organizations, particularly outreach-to-homeless veterans programs, and that their participation was encouraged.
Assemblyman Mabey inquired whether any faith-based groups were involved with the Advisory Committee on Homelessness.
Ms. Cory replied that no faith-based groups had been mandated to be included. She observed that many local providers throughout Nevada were faith-based organizations that were a part of various homeless coalitions and very much a part of the statewide provider community. Ms. Cory noted that there was a great deal of communication among policy-level decision makers and providers but there was some separation when speaking about who needed to “be at the table” in order to develop policy. She emphasized that the Policy Academy had operated in a very open manner, had received input from many providers, and hoped to continue receiving that input.
Assemblywoman McClain requested further information about the public information campaign. She asked whether Ms. Cory had heard about a bill being sponsored by Assemblyman Arberry to set up a referral service for people about to lose their homes.
Ms. McClain disclosed that she ran the senior advocate program in Clark County but added that passage of A.B. 259 would not affect her clients any more or any less than it would affect any other senior citizens. She noted that the “211 concept” of the single entry point for many services was being implemented and wanted Ms. Cory to be aware of that fact.
Ms. Cory replied that she was very aware of the “211 Initiative” and that the three United Way programs within Nevada were working with the Department of Human Resources in developing that program and were committed to being part of the team building the 211 calling system. She added that the United Way in Nevada ran an online information and referral service in conjunction with the Crisis Call Center.
In explanation of the public information campaign, Ms. Cory stated that it would use mainstream media such as radio and billboards to advertise who the homeless were, what their needs were, how they could be served, and to attempt to reduce the associated stigma. Ms. Cory wanted the campaign to reinforce the idea that homeless people were just like the rest of us and, should the need arise, the kinds of services that could be accessed.
Assemblywoman McClain requested that the campaign indicate to the general public that they might be just one paycheck away from homelessness themselves.
Mary Liveratti, Deputy Director, Department of Human Resources, expressed the Department’s support for A.B. 259 and supplied Committee members with a copy of her prepared remarks (Exhibit C). She noted that a number of the Department’s Divisions sat on the Policy Academy and added that creating the Advisory Committee would enhance coordination in the provision of services to Nevada’s homeless population. She indicated that current homeless services were fragmented across many agencies at both local and state levels and that passage of A.B. 259 would provide the state with the leadership needed to coordinate those services in order to address the problem.
Ms. Liveratti, responding to Assemblywoman Leslie’s remarks about the State Treasury, added that the Department of Human Resources was designated to receive the funds and that it would do everything it could to move the process along.
Assemblywoman Leslie replied that she was more concerned about the Board of Examiners and how long and difficult it was to get a state contract.
Linda Lera-Randle El, Executive Director, Straight From the Streets, a Las Vegas, Nevada, homeless outreach program, brought several people from the program with her. One formerly homeless man, Gerald Schmidt, had just received his General Education Diploma (GED) at the age of 60. Ms. Lera-Randle El explained that she ran her program out of her car and helped people who needed services to navigate the system, which she described as very dysfunctional and fragmented.
Connie Myer, a formerly homeless woman, testified as to how Ms. Lera-Randle El had helped her.
Ms. Lera-Randle El added that she coordinated services and taught individuals who were living on the streets where to access services. Some people could not survive shelter settings, she commented, so creative placements for those people needed to be supplied. She noted that people living on the streets taught other people living on the streets and that her biggest resource was the people on the streets who referred others to her. She reiterated that many street people could not navigate the system that was designed to assist them.
Ms. Lera-Randle El mentioned that she had been volunteering her services in this manner for 13 years and added that passage of A.B. 259 would allow all the providers to come together.
Chairwoman Koivisto asked if Ms. Lera-Randle El was a volunteer.
Ms. Lera-Randle El replied that money was not the best motivator for her so her husband worked two jobs so that she could volunteer. She observed that it was difficult to be an advocate if one was concerned with being politically correct or having one’s funding cut off. She added that sometimes it was not a matter of the availability of money, but how the money was utilized. Ms. Lera-Randle El added that her program provided bus tokens, phone cards, friendship, smiles, handshakes, and many things that could not be funded.
Assemblyman Horne observed that Ms. Lera-Randle El and her husband qualified as local heroes and thanked them for their services.
Chairwoman Koivisto indicated there were people in Las Vegas who had signed in to testify on A.B. 259.
Mark Nichols, Executive Director, National Association of Social Workers (NASW), Nevada Chapter, spoke on behalf of A.B. 259. He testified that the issue of homelessness was extremely complex and that he was in support of creation of the Advisory Committee. Mr. Nichols quoted from a portion of the NASW policy statement on homelessness, “To solve the problems of homelessness in the United States, public policies should focus on the changing social and economic conditions that foster extreme poverty and increase risk of homelessness.” Mr. Nichols indicated a need to address the issue of homelessness on every level. He also explained that he served on the board of directors of the Nevada Partnership for Homeless Youth, and that at the January meeting the board had unanimously passed a position statement supporting the concepts within A.B. 259 with the understanding that the Committee consider allocating one of the positions to someone with expertise and understanding of homeless issues as they related to children and youth.
Mr. Nichols explained that a youth sanctuary had been opened in Las Vegas 18 months previously. The homeless youth had been asked to name the sanctuary, and one suggestion had been to name it “Home Free.” He observed that many youth did not consider themselves “homeless,” indicating a very different perspective and very different needs.
Assemblywoman Leslie asked if Mr. Nichols were suggesting replacing one of the current positions or adding an additional position.
Mr. Nichols replied that there were three representatives from charitable or nonprofit organizations and that one of those positions could possibly be designated as the voice for homeless youth or that an additional representative could be added.
Ms. Leslie mentioned that the Western States Youth Services Organization was a regional group and that Nevada had a representative on that group, so perhaps someone from that organization could be recruited. She agreed someone on the Committee should represent youth.
Patricia Martinelli Price, Executive Director, Pulidor Foundation, explained that she had been a homeless advocate for women and children in Las Vegas for many years. Ms. Price encouraged ending homelessness. She also requested that the advertising campaign be respectful and not exploit homeless individuals. Ms. Price added that passage of A.B. 259 would help eliminate duplication of services.
Anthony Mosely, Director, God In Me Ministry, a 70-bed men’s transitional living facility in Las Vegas, stated that he had been a Las Vegas firefighter who had loved his career but that through stupidity he had lost his career and almost been homeless. He had rebuilt his life, founded his own company, and took over a failing ministry. He expressed support for A.B. 259 because it would bring many facilities under one umbrella so there would not be a duplication of efforts. He emphasized that homelessness could be solved and that his ministry was a vital key to aiding the homeless. The God In Me Ministry, he explained, was a safety net that provided 50-60 different services including clothing, food, housing, and help with job hunting. Eighty percent of the men the Ministry “caught,” he emphasized, never hit the street.
Brother David Buer, Founder, Poverello House, a daytime homeless house for men and women, expressed his support for A.B. 259. He observed that the Committee was seeing an example right in the hearing room of the kind of dialogue that resulted when people were brought together. Every human being who wanted shelter, he stated, should have it.
Pauline Salla, Director of Adolescent Services, Bristlecone Family Resources, a merged entity of SageWind and North Star, indicated her support for A.B. 259. She brought two successful young adults who had formerly been homeless youth to tell their stories.
Eseta Kaufusi explained that her mother had moved to Alaska and left her alone, but that even prior to her abandonment, her home life had not been a good one, so she had lived on the streets off and on from the age of 12 until she was 17 and was sent to SageWind. SageWind had helped with treatment and also offered her a home, a bed, and a family, she said. In addition, SageWind had offered access to career counselors and many other opportunities such as help with school and help finding a job. Ms. Kaufusi added that she was currently enrolled at Truckee Meadows Community College and had been working at the same job for over a year.
Jacob Davis emphasized that most people did not understand the youth of today. He said that he had loved living on the streets because of the availability of drugs and money, and that he had never wanted to stop until he had realized that the life he was living was wrong and that he was hurting people. He was arrested and institutionalized numerous times until finally he was sent to SageWind. After one stay at SageWind, he had returned to the streets and been arrested again. SageWind had taken him back after a long trial period, and this time the program had worked and he had his first job, would be graduating from high school a year early with a 3.5 grade point average, and planned to go to college. Mr. Davis attributed his success to SageWind, which brought youth in off the street and provided them with jobs and a place to live. He reiterated that without SageWind, he would be occupying one more bed at the state prison. Mr. Davis encouraged passage of A.B. 259.
Assemblywoman Leslie thanked the youth for being present at that day’s hearing and asked, if the bill were amended to have a representative specifically for homeless youth, whether an older homeless youth would be willing to put in the work necessary to serve on such a committee.
Ms. Kaufusi indicated that she thought it would be a good idea.
Mr. Davis thought it might be difficult to find someone his age with the time. He added that it did not matter how old the representative was and that someone like Pauline Salla might be a better choice because she knew the youth culture.
Elizabeth Dorway, Board Representative, Jubilee Center, explained that Jubilee Center was a daytime drop-in center for the homeless with mental health issues in Carson City. She indicated that in the past two years, 508 new clients had been seen at the center, and she asked that consideration be given to Carson City and the surrounding area when appointing representatives to the Advisory Committee.
Bob Caldwell, Jubilee Center, stated that he was one of the homeless in Carson City. He submitted a paper to the Committee entitled, “Imagine The World Without Them” (Exhibit D) that enumerated the contributions of the mentally ill, both past and present. Mr. Caldwell grouped the homeless into four categories: the downtrodden, the mentally ill, the veterans, and the youth.
Jean Roberts, Executive Director, Jubilee Center, explained the Center had been in operation for two and a half years, and served 25-30 “members” each day. There was a phone available to the members for job searches and other things, as well as a volunteer from Carson Mental Health who had begun to evaluate members for treatment. She expressed her support for A.B. 259 and reiterated Ms. Dorway’s request for a Carson City representative on the Committee.
Michael Stoops, Director of Community Organizing, National Coalition for the Homeless, indicated support for the passage of A.B. 259. He mentioned that several states had legislated state interagency councils on the homeless to coordinate services, do research, and provide funding. Mr. Stoops criticized the bill in one area, stating there should be more than one homeless person on the Committee, and that the homeless representative should be a currently homeless person.
Chairwoman Koivisto asked whether anyone was opposed to the bill, but no one responded. She indicated that A.B. 259 would be re-referred to the Assembly Ways and Means Committee.
ASSEMBLYWOMAN McCLAIN MOVED TO DO PASS A.B. 259 AND RE-REFER TO THE ASSEMBLY WAYS AND MEANS COMMITTEE.
ASSEMBLYMAN WILLIAMS SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Chairwoman Koivisto indicated the next bill to be heard would be taken out of order.
Assembly Bill 430: Prohibits Department of Human Resources from taking certain actions to restrict access to prescription drugs for mental illness provided pursuant to Medicaid. (BDR 38-984)
Assemblywoman Sheila Leslie, Washoe County District No. 27, explained that A.B. 430 restricted the Department of Human Resources from using a preferred drug list to restrict access to certain classes of drugs, such as atypical and conventional anti-psychotic medications for mentally ill people, anti-depressant medications, anti-anxiety medications, and anti-convulsant medications. Ms. Leslie noted that certain new drugs or expensive medications were often not on preferred drug lists, which made it impossible to adequately treat certain mental illnesses. She added that preferred drug lists were in place to help states take advantage of rebates offered by pharmaceutical companies but that the lists were meant to include a variety of drugs. If a drug was not on the list, she commented, the doctor had to obtain prior authorization before prescribing it to a Medicaid patient.
Ms. Leslie mentioned that she understood the current budget situation and the difficulties of balancing policy with money; however, she noted that she had discussed the situation with state Medicaid administrators who had agreed to exclude certain anti-psychotics and anti-convulsants from the preferred drug list. She added that the preferred drug list was currently in the process of being established but that the issue of anti-convulsants and anti-anxiety medications remained to be addressed. Ms. Leslie also noted that an amendment to also exclude HIV drugs from the list would be introduced as well, which she was in support of.
James Vilt, Nevada Advocacy and Law Center, read his testimony in support of A.B. 430 from prepared text (Exhibit E). He explained that the Nevada Advocacy and Law Center was Nevada’s federally mandated protection and advocacy system for individuals with disabilities. Mr. Vilt stated that the ability of people with serious mental illness to thrive in a community was largely dependent upon their willingness to manage the symptoms of their mental illness. Considering the scarcity of community supports for Nevadans with serious mental illness, medication was often the predominant or only tool those individuals were given, he noted. Mr. Vilt explained that if access to the medication those individuals preferred was restricted, which was often the newer generation drugs, some of those people might choose to stop taking their medication, as they might find the side effects less bearable than the symptoms of the illness the drug was to treat. Mr. Vilt observed that when individuals stopped taking their medications, the impact was felt by families, hospitals, and the criminal justice system, as well as by the individual himself.
Mark Armerding, M.D., Nevada Psychiatric Association, spoke in favor of A.B. 430. He expressed the view that physicians and other prescribers needed to be able to exercise good clinical judgment and to have full access to medications in order to treat mental illness. The illnesses, he emphasized, could be very difficult to treat and oftentimes, different medications needed to be used because on occasion only one medication would work for a particular patient. A restricted list, Dr. Armerding commented, might result in such medications not being available to the provider or the physician.
Dr. Armerding acknowledged that some medications were very expensive, but observed that if the patient did not have access to that medication, the result could be increased visits to emergency rooms, increased use of hospital beds, increased costs, and lessened ability to function.
Pat Coward, GlaxoSmithKline, proposed a friendly amendment to A.B. 430 (Exhibit F) dealing with the human immunodeficiency virus (HIV). Mr. Coward’s amendment would add anti-retroviral prescription drugs prescribed for a person infected with HIV to the list of drugs not restricted for use by a preferred drug list or the requirement for prior authorization.
Tom Wood, Wyeth Pharmaceuticals, stated he was also representing himself and his family, several of whom suffered from various forms of mental illness. He testified that if any drugs were restricted, the provider would be unable choose the drug most efficacious in a particular situation. Mr. Wood added that people with brain disorders reacted differently to various different medications and that the proper medication could result in fewer emergency room visits, fewer hospitalizations, and less money spent by the criminal justice system. He added that Oregon had just “stripped” a number of people of their medications and that, as a result, many incidents, including suicides and/or injuries had occurred.
Assemblywoman Weber, noting that A.B. 430 was concerned with mental health drugs, asked Mr. Coward why he had proposed his amendment to that bill.
Mr. Coward replied that the “linkage” was because of the treatment choices a provider or physician would have. He added that with HIV there was not much opportunity to test the success of the drugs.
Ms. Weber asked if there were another vehicle for Mr. Coward’s amendments.
Mr. Coward answered that many states with similar legislation had incorporated mental health and HIV medications in the same statutes.
Assemblyman Hardy asked, if one were not able to test the effectiveness of a drug on HIV, how it could be said that one drug was more effective than another. Referring to the “Oregon experience,” he asked if there were anything in the medical literature about the reality of suicide increases and injury increases in Oregon and if so, could the Committee have a copy of the study.
Mr. Wood answered that the press had reported anecdotal evidence of increased suicides and injuries, but that no study had been done. He added that when people went off their medications, they committed suicide. He said that he would try to get information on the Oregon situation to the Committee.
Chairwoman Koivisto and Assemblyman Hardy both agreed they would like to see any evidence Mr. Wood could find.
John Kimbrough, Account Director, State Government Affairs, GlaxoSmithKline, responding to the question concerning inclusion of HIV drugs in A.B. 430, replied that the medications were almost always given in threes and fours, in a very regimented manner, one step at a time, whenever there was an advanced case of HIV. If the medication were not given successfully, the patient would be hospitalized with very critical conditions. If all the medications were available, the virus could be put into such a state that the patient would be functional.
Assemblyman Hardy mentioned that there were protocols in HIV treatment and that A.B. 430 was not discussing changing protocols as much as looking at availability of appropriate medication. He asked if there had been a proposal to change the protocol availability to the clinician for a particular patient.
Mr. Wood answered that the proposed amendment and the bill were not intended to address protocols or algorithms, but that the parties to the amendment wanted all the medication available should a patient get to a therapeutic category in a protocol.
Chairwoman Koivisto asked Mr. Charles Duarte for an explanation.
Charles Duarte, Administrator, Division of Healthcare Financing and Policy, pointed out to the Committee that in developing a preferred drug list, it had been the Division’s intention to utilize clinical experts as part of an evaluation team and to have them, without regard to cost, make decisions on all the therapeutic categories based on clinical efficacy and safety. He emphasized that patient safety was a critical concern to the Division.
Mary Wherry, Deputy Administrator, Division of Health Care Financing and Policy, read her testimony from prepared text (Exhibit G). She noted that the Nevada Medicaid program complied with federal regulations in the Social Security Act for the Medicaid drug rebate program and outpatient pharmacy coverage. Ms. Wherry added that Nevada operated under an open formulary but managed expenditures and utilization control through a prior authorization drug schedule, quantity limitations, clinical step therapy protocols, upper limits on pricing, and appropriate provider/recipient education.
Ms. Wherry explained that Nevada Medicaid’s fee-for-service prior authorization policies and step therapy protocols used clinically based criteria developed by a Drug Utilization Review Board and approved by the Division’s Medical Care Advisory Committee, which was made up of medical professionals. Ms. Wherry noted that decisions as to whether to implement Medicaid step therapy protocols or prior authorization policies for mental health drugs would be left to clinical experts. She added that in development of a preferred drug list, the Division had committed to excluding atypical and typical anti-psychotics and anti-convulsant medications due to the sensitive nature of those drugs. Ms. Wherry requested that the Committee adopt an amendment that would allow a clinically based pharmacy and a therapeutic committee to decide if it was necessary to exempt anti-depressant and anti-anxiety medications. She added that those drugs would continue to be available, even if they were placed on a preferred drug list, and that Medicaid currently spent approximately $1.4 million just for those two therapeutic drug classes.
Assemblywoman McClain asked which two drugs Ms. Wherry was referring to.
Ms. Wherry explained that the $1.4 million was spent on anti-anxiety and anti-depressant drugs and that those were the two classes the Division was asking to have amended and excluded from A.B. 430.
Ms. McClain asked if those two classes of drugs were excluded from A.B. 430, if it would mean that they would need prior authorization.
Ms. Wherry answered that if they were excluded from the bill, the Pharmacy and Therapeutics Committee would be asked to make a decision as to whether or not it would be clinically appropriate to have those drugs on or off a preferred drug list.
Assemblywoman McClain, referring to the four drug categories listed in A.B. 430, asked what the differences were among those drugs and why the Division was splitting them between atypical and typical anti-psychotics.
Ms. Wherry answered that atypical and typical anti-psychotics were primarily used to treat people with bipolar disorder, manic-depressive disorder, or people with some type of schizophrenic disorder. Anti-convulsants, she noted, were typically used to treat people with bipolar disorder, but were also used to treat younger children when the clinical criteria were vague and their diagnostic criteria not clear. It was also used oftentimes for people with schizophrenia or similar disorders, Ms. Wherry noted. In the therapeutic classes of anti-depressants, she continued, there was a lot more commonality, clinically speaking. There were some diagnoses like obsessive-compulsive disorder, that might respond better to one drug than another, and at that time, she noted, the Therapeutic Committee would be asked to determine “whether or not there would be a very narrow margin” or whether it would be acceptable to just have that drug go through the prior authorization (PAR) process. Anti-anxiety medications, she observed, were sometimes used for people with depression, but were typically used for people who had some type of agoraphobia or panic attack or some kind of anxiety disorder. She noted that they could be very effective, but could also be used and prescribed as the anti-depressants by family practitioners.
Chairwoman Koivisto asked Ms. Wherry if she had an opinion about the amendment proposed by MM. Coward, Wood, and Kimbrough.
Mr. Duarte answered that, as it related to Medicaid, those drugs were already excluded from consideration on the preferred drug list as well as some other medications, including immunologic medications used to suppress adverse responses to transplants, anti-diabetic medications, and anti-hemophilic medications, necessary for blood clotting disorders. He added that there was a broad category of exclusions from the preferred drug list. Mr. Duarte stated that the Division would like to allow the Pharmacy and Therapeutics Committee to evaluate drugs based on clinical data, and then to determine their safety and efficacy before inclusion on a preferred drug list.
Mr. Duarte observed that there were financial issues at stake and a budget that had to be adhered to, but he appreciated the concerns of the clinical representatives at the hearing and the recipients of the medications. Mr. Duarte emphasized that it was not the Division’s intent to harm recipients or deny them medications, and he reiterated the need for fair evaluation by clinicians and experts who could determine whether a few drugs in a therapeutic class were equally effective and could be placed on a preferred drug list.
Assemblywoman McClain asked whether the drugs were evaluated ahead of time, or every time someone received a prescription.
Mr. Duarte explained that an individual would not need to be evaluated every time a prescription was written. He noted that there were certain conditions what would cause a physician to note, for instance on a priorauthorization form, that it would be clinically appropriate to prescribe a non-preferred drug for a recipient. The Division would like to develop a program that would leave room for that kind of clinical judgment to be exercised and for the Division to approve an alternative choice.
Ms. McClain commented that the Division probably already had a number of “exceptional” drugs on its PDL.
Mr. Duarte agreed that the Division did and that there were exceptional situations when a particular diagnosis warranted the patient be prescribed a drug that was not a preferred drug.
Ms. Wherry pointed out that an example might be if the Pharmacy and Therapeutics Committee decided to have the anti-depressant therapeutic class on the preferred drug list. Through the prior authorization process, if a recipient had an obsessive-compulsive disorder and the physician wanted to use Paxil, assuming it was not one of the drugs recognized for the supplemental rebate or one of the preferred drugs, the physician could still write a prior authorization request and the patient could still receive that particular drug for that particular reason.
Ms. McClain explained that she was still trying to determine how many drugs would be considered the exception and need prior authorization.
Ms. Wherry replied that the Division would be better able to track when that happened because of implementation of the pharmacy point-of-sale system and the Medicaid Management Information System (MMIS) system soon to come on line. She added that 18 months previously there had been prior authorization requests for anyone who had more than three prescriptions a month. Once the prior authorization process was contracted out, and the Division could look at solid data, if it were learned that 99 percent of the time the drug was being authorized beyond the three prescriptions, then that drug was removed from the prior authorization request list. If a drug was heavily approved, she reiterated, the prior authorization process would not be required.
Mr. Duarte added that 97 percent of the prescriptions for atypical antipsychotics did not require prior authorization because they were on the preferred drug list.
Ruth Paxton, R.N., President, National Alliance of Mental Illness (NAMI), Carson City Chapter, referenced a drug formulary report by Dr. Carlos Brandenburg, Administrator of the Division of Mental Health and Developmental Services (DMHDS) (Exhibit H). She stated that the report indicated the creation of a new committee, the Pharmacy Oversight Leadership Committee, which would consist of 3 psychiatrists, 1 pharmacist, and 7 non-medical personnel. Ms. Paxton expressed alarm that the people on the Pharmacy Oversight Committee would be making medical decisions and added that the “non-medical person would always override the medical person in making these medical decisions that were important.” She commented that the main objective of the Oversight Committee was cost containment.
Ms. Paxton referenced a study by the Brazleton Psychiatric Center that indicated controlling access to medications for mental illness was harmful to the patient. The study clearly stated that the additional hospitalization costs per patient per year were approximately $35,000 when the patient “failed out” of the program. Ms. Paxton maintained that “Dr. Brandenburg’s fail first system” was created as a cost-saving program and that because he was a psychologist and not a psychiatrist with a medical degree, he “was poorly equipped to make medical decisions.” She stated that the drugs Dr. Brandenburg had chosen for the program were not good choices because they were two drugs from the same drug class. Ms. Paxton reiterated that the states that had tried a similar program had had increased hospitalization expenses because every time the patient “failed out” of one of those drugs, that patient would be back in the hospital after a “psychiatric event.”
Ms. Paxton noted that Nevada received many free mental health drugs because for every paid prescription, four free drug prescriptions were given away under the Drug Enrollment Program. She noted that the drug companies could not be relied upon to provide free drugs indefinitely, which was of great concern because much of the budget, particularly in the rural clinics, was based on free drugs from the Drug Enrollment Program. Ms. Paxton expressed strong support for decisions concerning medications being made solely by the treating psychiatrists.
Chairwoman Koivisto requested that Ms. Paxton repeat the makeup of the Oversight Committee.
Ms. Paxton recited the names of the Pharmacy Oversight Leadership Committee beginning with Carlos Brandenburg, Harold Cook, and Larry Buel, all psychologists; David Rosin, Larry Montgomery, and Ira Pauly, psychiatrists; Jonna Triggs, who had a doctorate in education; Mark Depew and Emmanuel Ebo, pharmacists; Debbie Hosselkus from DMHDS; and Bob Harnish, Statewide Pharmacy Director, DMHDS.
Assemblyman Hardy observed that there were three psychiatrists, medical doctors specializing in those medications, on the Oversight Committee and he commented that three physicians could possibly “be enough.”
Ms. Paxton answered that the physicians had only 3 votes on the 11-member committee and could easily be overridden.
Mr. Hardy commented that he had yet to meet a doctor who was easily overridden.
Ms. Paxton responded that she had met many doctors who could be easily overridden.
Mr. Duarte stated that he had not been involved in the development of the Nevada Specific, Texas Medication Algorithm Program (TMAP), but that he understood that Dr. Brandenburg had enlisted a number of physicians and pharmacists in the development of that effort. He volunteered to express the Committee’s concerns about the make up of the Pharmacy Oversight Leadership Committee to Dr. Brandenburg. Mr. Duarte added that he did not believe it had been Dr. Brandenburg’s intent to override appropriate medical decisions, and that the protocol did give flexibility to the physician to not utilize the Nevada- specific TMAP protocol.
Assemblyman Mabey mentioned that oftentimes his patients requested anti-depressants, and that many times they were warranted. Many patients, he noted, responded to the different anti-depressants such as Prozac, Paxil, Zoloft, Lexapro, or Celexa, and he noted that if he were writing a prescription for a Medicaid patient, he would be allowed to prescribe any of those medications. He observed that it seemed as though for an obstetrician/gynecologist like himself or for a general practitioner it might be helpful and save money for the state if only one or two anti-depressants were used initially. Afterward, he added, if that drug were not successful, the physician could try another. He observed that a psychiatrist, on the other hand, would need to have the bill the way it was written.
Rachael Paxton, R.N., NAMI, maintained that Carlos Brandenburg had the “ability to override all decisions as far as medication was concerned.” Referring to the tier system, which did involve anti-depressants, she indicated that the only prescription that could be written was for Fluoxetine. She emphasized that mental health was the only area of health care where diseases were treated based on the dollar and not on the physician’s diagnosis.
Assemblyman Mabey replied that he would not know if a drug such as generic Prozac would work just as well as Paxil or Zoloft until he tried the drug.
Rachael Paxton responded that if a patient could not take “SR-1s and needed to take SR-2s,” that option was not allotted for on that tier. A medical doctor, she reiterated, would not make the prior authorization approval.
Mr. Duarte clarified that implementation of a preferred drug list for Medicaid and prior authorization decisions would be left to the Pharmacy and Therapeutics Committee. He noted that there was a Drug Utilization Review Board made up of physicians and pharmacists, consistent with provisions of the Social Security Act that made all those decisions. He emphasized that the Review Board was a clinically based and independent body. Mr. Duarte indicated the need for a consistent policy because many patients served by Medicaid were the same patients who were served by the Division of Mental Health and Developmental Services.
Assemblyman Hardy, referring to tiered medicines, stated that if there were a contract providing generic Prozac at a set price, and the prices for Paxil, Celexa, and Lexapro, for example, were at a different price, the practitioner would still have the option of writing for the other medicine. He noted “Medicaid would pay the same price for the other medicine with a ‘quasi-contract’ for the other medicines being covered under that same price, but the practitioner would still be able to use those medications.”
Mr. Duarte replied that Assemblyman Hardy was correct. He added that if the preferred drug list were to “go forward,” drugs of equal efficacy and safety within a therapeutic class, after evaluation by the Pharmacy and Therapeutics Committee, would be reviewed by the accountants. Afterwards, for those drugs that were equally effective, a preferred drug would be selected. Mr. Duarte stated that the manufacturer could rebate down to that preferred price for drugs determined to be equally effective, and then a prescription could be written without prior authorization. For a manufacturer-labeled drug that was not included in the supplemental rebate program, Mr. Duarte noted, there would be a prior authorization required. If that drug were needed, he emphasized, that need would override any edits in the system and would be allowed for that patient. The formulary would still be open, Mr. Duarte added, but it would be controlled through an appropriate, clinically based, prior authorization process.
Assemblyman Hardy commented that in reality, the number of prior authorizations needed would be reduced through market force bargaining, which would allow obtaining other medicines that were not on the formulary itself. He observed that when the doctor talked to a person with depression, the doctor was treating the whole person and that some of the side effects of certain medications might be desired, so the side effect and effectiveness profiles of one particular medicine might be best for that person. Assemblyman Hardy noted that the classic example was prescribing Wellbutrin for someone who was depressed and wanted to quit smoking because it could do two things at once. Mr. Hardy reiterated that there might be advantages that did not appear in the protocol to prescribing one medicine over another and that A.B. 430 would allow a trained medical practitioner to make an appropriate decision. He added that the concept of allowing freedom of choice was good, but at the same time he applauded Mr. Duarte’s efforts to craft a program that allowed the practitioner to have that kind of freedom in a fiscally responsible way.
Rachael Paxton expressed her support for passage of A.B. 430. She explained that people with mental health problems could frequently become productive members of society and lead normal lives when prescribed the proper medications. She noted that medications for virtually all other types of illnesses treated under the Medicaid system were chosen based on the patient’s needs and diagnosed illness and that nowhere else in the state’s system did a sick person have to spend 12-24 weeks getting to the correct medication tier. Ms. Paxton said that over 60 percent of the people who committed suicide in Nevada were suffering from some type of untreated depression or mental illness.
Chairwoman Koivisto brought A.B. 430 back to the Committee and announced that action on the bill would occur during a work session. She also stated that A.B. 297 was being held. Chairwoman Koivisto then opened the hearing on A.B. 402.
Assembly Bill 402: Revises requirements concerning approval of certain construction on behalf of health facility. (BDR 40-816)
Assemblyman Rod Sherer, District No. 36 (Esmeralda, Lincoln, Mineral, Nye Counties and portions of Churchill County), thanked Committee Policy Analyst Marla McDade Williams for her assistance with the research involved in crafting A.B. 402. He explained that A.B. 402 would change some of the provisions to the state’s Certificate of Need (CON) process. Mr. Sherer said that Pahrump currently had no 24-hour healthcare facility, but that Pahrump Health Facilities and Rural Health Management Corporation had started the CON process in July 2002 to get approval to build a 25-bed hospital in Pahrump. Mr. Sherer proposed a change to the CON process that would only apply to Pahrump so that, should something occur and Rural Health Management not build the hospital, Pahrump would not have to wait an additional two years to get through another CON process. Mr. Sherer explained that after-hours emergency care in Pahrump involved either a one-hour drive or an $8,000 one-way helicopter ride to Las Vegas.
Assemblywoman Weber asked when the Pahrump hospital would be open for business.
Assemblyman Sherer stated that if Rural Health Management did not meet the time line for construction of the hospital and lost the CON, parameters would be in place so that the entire CON process would not have to be done all over again. Someone would have to be issued a CON and start the work he noted, but would not have to go through “all the hoops” again.
Assemblywoman Angle expressed her support for A.B. 402, adding that it would streamline the process.
Chairwoman Koivisto inquired what would happen if Pahrump become a city.
Ms. Sherer answered that he did not anticipate that happening.
Chairwoman Koivisto replied that she had asked the question because Pahrump had, on numerous occasions, attempted to become a city and if that happened, the bill would do the city no good.
Mr. Sherer answered that he hoped to have a hospital before Pahrump even became an incorporated town.
Roy Barraclough, Project Development Officer, Rural Health Management Corporation, and Project Manager for the new hospital being constructed in Pahrump by Rural Health Services Corporation, an affiliate of Rural Health Management Corporation, read his testimony from prepared text (Exhibit I). He noted that A.B. 402 proposed to amend the CON law and would exempt unincorporated townships from the CON review process if they met certain criteria relating to population, health service availability, and distance from the nearest trauma center services.
Mr. Barraclough also indicated support for the CON law and wanted to caution that a precedent not be established that would facilitate additional, unwanted changes to the CON law. The CON law, he emphasized, protected rural hospitals from the negative and potentially disastrous effects of competition from large, well-resourced health systems or provider groups that might come to rural communities and “cherry pick” the existing hospital’s service area by offering high-profit-margin services such as diagnostic imaging or ambulatory surgery in direct competition to that hospital. Mr. Barraclough noted that those were the very services that allowed rural facilities to remain in business and to generate profit margins sufficient to help offset the operational losses typically experienced by other services in the hospital such as the emergency room and, in some cases, obstetrics.
Mr. Barraclough suggested that maintaining financial viability was a challenging assignment for any hospital, especially for rural hospitals, and he added that Rural Health Management Corporation estimated cash flow shortfalls for the first 12-18 months of operations for the Pahrump hospital. He noted that the importance of rural hospitals to the economy, safety, and quality of life in a rural community was well established, and any future changes in the CON law that would make it possible for niche marketing to occur in a rural community, could compromise a rural hospital’s capacity to maintain financial viability, once established.
In conclusion, Mr. Barraclough encouraged the Committee to pass A.B. 402 if it believed passage of the bill was appropriate, but requested that the bill not be the forerunner that could weaken, or ultimately remove, CON protection for rural Nevada communities.
Assemblyman Hardy asked if it would be possible in the CON process to look at A.B. 402 as allowing the door to be opened for a period of time and then closed after the hospital was built. He proposed an amendment that would allow the hospital to be built and afterward any other medical facility over the $2 million cap would have to go through the CON process.
Mr. Barraclough observed that, in effect, that was what was currently happening. The Pahrump project was well underway, had its CON, was in the final stages of financing arrangements, and the hospital was scheduled to be completed and operational by November 2004.
Mary Griffith, Health Resource Analyst, Bureau of Health Planning and Statistics, State Health Division, read her testimony from prepared text (Exhibit J). She explained that construction of new health facilities costing more than $2 million in Nevada counties with populations of fewer than 100,000 people required a letter of approval from the Director of the Nevada Department of Human Resources, and was known as the Certificate of Need process.
Chairwoman Koivisto noted that Pahrump already had a CON and was building its hospital and she observed that A.B. 402 was insurance against something happening to the current project, so Pahrump would not be required to go through the CON process again.
Ms. Griffith answered, “Basically, yes.”
Robin Keith, President, Nevada Rural Hospital Partners, President, Nevada Rural Hospital Partners Foundation, commented that the Nevada Rural Hospital Partners’ position on A.B. 402 was officially neutral. She expressed appreciation to Assemblyman Sherer for his willingness to work with the rural hospitals and indicated that she understood his position because Pahrump had been through the CON process twice.
Ms. Keith emphasized the importance of preserving the protection of the new Pahrump hospital from cherry picking and suggested an amendment that would involve inserting a few words on page 2, line 14 of the bill. She explained that A.B. 402 was exempting the construction of a hospital in a community that met certain specific definitions and happened to be Pahrump. The exemption, she noted, was for a project for the construction of a hospital in an unincorporated town and suggested defining that more fully by saying, “the construction of a general, acute care hospital,” which would prevent a specialty hospital from coming into the community under the exemption.
Chairwoman Koivisto observed that the definition of a hospital in the Nevada Revised Statutes would be changed.
Ms. Keith suggested that a sunset provision be considered for the bill as a whole.
Chairwoman Koivisto noted that line 18, page 2, of A.B 402 addressed that issue.
Ms. Keith explained that she was concerned that once the Pahrump hospital was built, there was nothing to prevent another specialty hospital from being built.
Chairwoman Koivisto explained that if another hospital wanted to move into Pahrump, it would need a Certificate of Need.
Ms. Keith agreed with her and added that since the exemption in A.B. 402 only related to hospitals, imaging centers, ambulatory surgery centers, et cetera were already covered under the CON. She reiterated the neutrality of the Rural Hospital Partners on the bill but also indicated their support for the development of a hospital in Pahrump.
Assemblyman Horne noted that Assemblyman Sherer wanted a hospital.
Assemblywoman Pierce requested assurance that the definition in A.B. 402 only applied to Pahrump.
ASSEMBLYMAN HORNE MOVED TO DO PASS A.B. 402.
ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Assembly Bill 501: Makes various changes to provisions governing welfare and other programs of public assistance. (BDR 38-516)
Nancy Ford, Administrator, Department of Human Resources Welfare Division, read her explanation of A.B. 501 from prepared text (Exhibit K). She explained that A.B. 501 would provide additional flexibility to the Welfare Division and clean up some matters within Chapter 422 of the Nevada Revised Statutes. She noted that Temporary Assistance to Needy Families (TANF) was up for reauthorization by Congress this year and that the Division wanted the ability to address any changes that might need implementation.
Ms. Ford observed that A.B. 445, which had already passed out of the Committee, addressed Sections 11-14 and 24-28 of A.B. 501. She went on to enumerate various other areas of the bill.
Assemblyman Horne, referencing the reduction in meeting notice time from 45 days to 14 days, asked if there was any downside to the change.
Ms. Ford replied that public bodies could meet with three-business-days’ notice, according to the Open Meeting Law. She added that, as the Welfare Board was now an advisory group and no longer adopting regulations, the 14-day meeting notice was longer than required.
Mr. Horne observed that the Board was a public body providing aid and care.
Leslie Danihel, Chief, Eligibility and Payments, Welfare Division, Department of Human Resources, explained that the 45-day requirement for meeting notices was originally based upon the Welfare Board being a regulatory committee. The TANF program, she added, still required a 45-day public comment period for regulations, but regulations for the TANF program were now passed through a separate public hearing process. Ms. Danihel indicated that there was no down side because the regulations still had a 45-day public comment period. She noted that the Welfare Board now assisted the Welfare Division with proposed changes in policies, looked at trends, and gave the Welfare Division advice on suggested areas of research, so the public notice requirements were much different and had much less bearing upon matters being discussed. Ms. Danihel explained that it was very difficult to maintain a quorum with the 45-day meeting notice requirement for an advisory committee because oftentimes members’ schedules had changed in the meantime.
Assemblyman Horne, referencing Section 18, expressed concern that “emergency situations” were not being defined in A.B. 501 and that it might become a standard procedure that aid be provided and the assessment not get done. If the assessment indicated that a recipient should not have received aid, there would be no way to recoup the money provided by the Welfare Division, Mr. Horne observed.
Ms. Ford replied that the assessment referenced in Section 18 was for work skills and not eligibility for aid.
Mr. Horne emphasized how important the Kinship Care program was and added that he was very hesitant to change from a mandate to the permissive language.
Ms. Ford explained that the Kinship Care program was in addition to another program the Welfare Division had called “non-needy caretakers” who were relatives of children and who were of any age. She added that the average age of non-needy caretakers was 49. Kinship Care, she observed, was designed to handle a population that was likely to be retired and on fixed incomes and to whom a higher grant would be given than any other TANF recipient received.
Assemblywoman McClain referenced the bottom of page 4 of A.B. 501 and questioned why the mandate to evaluate recipients of public assistance who were victims of domestic violence and to refer them to different programs was being removed and made permissive.
Ms. Ford answered that the Welfare Division had wondered the same thing but had been looking for flexibility to address possible new time frames in the new federal TANF reauthorization. She added that if the Committee wanted to leave the language “shall,” the Division would have no objection. Ms. Ford emphasized that there were a lot of strings to the TANF block grant.
Assemblywoman McClain expressed concern that if something was low priority at the federal level the state would elect to not address the situation at all, and that the state should have some guidelines, whether TANF required them or not. Speaking of the Kinship Care program, Ms. McClain asked for reassurance that caregivers were thoroughly checked out during the custody hearings.
Ms. Danihel replied that state statute required that no person convicted of a felony be certified as a guardian. She added that during the time background checks had been conducted, there had only been two positives; one had been self-declared prior to the fingerprint check, and the other had been a 62-year-old person who had been convicted as a teenager, but whose record had been clean since.
Assemblyman Hardy asked if it was stated anywhere in A.B. 501 that the intent of the bill had been compliance with federal laws and regulations. He observed that federal laws and regulations required reporting intervals and time periods and inquired if such language existed so that the state would not develop different reporting intervals and time periods.
Ms. Ford replied that, as a general rule, federal law took precedence, and the Welfare Division wanted to avoid a conflict between federal law and state law. She noted that people generally did not consult federal laws but occasionally they looked at state laws so she wanted Nevada’s laws to be synchronized as closely as possible with federal laws. If the Welfare Division had the flexibility to adopt by regulation, she added, when people consulted the state’s regulations they would be aligned with federal laws. Ms. Ford was hoping to avoid conflict, which raised more disputes and questions.
Chairwoman Koivisto asked the Committee if it wanted to leave the language “shall” evaluate recipients who were victims of domestic violence. There was no response.
Jan Gilbert, Progressive Leadership Alliance of Nevada, expressed support for A.B. 501 and stated that she had worked with the Welfare Division in the interim on many issues in the bill. She said that the change in the Welfare Board’s meeting notice was an advantage for the Leadership Alliance. She explained that the issues taken up by the Board were very timely and if they had to comply with a 45-day notice, the agenda might be set too far in advance to allow discussion of federal issues that might be more pertinent.
Ms. Gilbert commented that the issue of fingerprints had been taken to the Welfare Division by the Leadership Alliance during the interim because fingerprinting had been found to be difficult and expensive for many of the grandparents.
Discussing the removal of the “sanctions” in Section 22, Ms. Gilbert expressed her belief that the language had been punitive and cumbersome. Discussing the change in the domestic violence section to “shall,” she expressed concern that it might create too large a fiscal note. Ms. Gilbert urged support for A.B. 501.
Chairwoman Koivisto explained that the amendment that had been under discussion was to leave the word “shall” in the statute instead of substituting the word “may.”
Ms. Gilbert replied that she was responding to some Committee members’ concerns. She added that she supported evaluation of every client for domestic violence, but was concerned that the Division was running out of money.
Chairwoman Koivisto stated that A.B. 501 would be heard in a work session and adjourned the meeting at 4:02 p.m.
RESPECTFULLY SUBMITTED:
Terry Horgan
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairwoman
DATE: