The Committee on Health and Human Services was called to order at 1:40 p.m., on Wednesday, February 24, 1999. Chairman Vivian Freeman presided in Room 3138 of the Legislative Building, Carson City, 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. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Merle Berman

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

Mr. Wendell Williams

COMMITTEE MEMBERS ABSENT:

Ms. Sharron Angle

GUEST LEGISLATORS PRESENT:

Assemblywoman Jan Evans

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Assemblywoman Jan Evans identified herself as representing District 30 and introduced Vince Juaristi, the primary researcher of A.B. 181. Ms. Evans said the bill had been titled the "Kick Drugs Bill." The bill:

• Expanded residential outpatient detoxification evaluations and transitional housing services for children with substance abuse problems.

• Provided better coordination between substance abuse treatment and the treatment of mental illness.

• Established three pilot projects in Family Resource Centers to provide low-level drug abuse intervention programs.

• Moved the Bureau of Alcohol and Drug Abuse (BADA) from the Department of Employment Training and Rehabilitation (DETR) to the Department of Human Resources (DHR).

• Required the Nevada Drug Commission to provide a standard substance abuse report card to be published annually.

Ms. Evans said consideration of the bill came at a very good time. During the interim period a study committee created by A.C.R 57 of the 69^th Session had focused on juvenile justice issues. Testimony had been given in the committee on the issues of education, prevention, and treatment programs for youngsters, recognizing substance abuse had a high correlate to juvenile crime and delinquency. Many witnesses voiced concern about how the programs operated in Nevada and their effectiveness.

Vince Juaristi identified himself as Director, Nevada Institute for Children, University of Nevada Las Vegas (UNLV). The Nevada Institute for Children provided research on children's issues, from prenatal care to high school dropout rates, depending upon where the need had been greatest for the research. The institute proposed policies based on research to advance children's causes and rallied the community to advance those causes and activities. A.B. 181 had been a product of one of the studies completed through a process used at the Nevada Institute for Children.

There were two policy boards for the institute, one in the northern and rural areas comprised of various organizations and community leaders, and one in the southern part of the state of similar composition. The boards reviewed the institute's research and policies then developed activities and legislation that benefited children.

Mr. Juaristi provided a booklet titled "Helping Kids Kick Drugs: Residential and Outpatient Treatment Services for Adolescents," (EXHIBIT C, Part 1) published by the Nevada Institute for Children. The booklet detailed a survey of about 5,000 households conducted by a research institute at University of Nevada Reno (UNR). The results of the survey provided the basis for data contained in

A.B. 181. Additional data had been provided by the:

• National Drug Survey (EXHIBIT C, Part 2)
• Nevada Youth Risk Behavior Report issued by the Department of Education
• University of Maryland Center for Substance Abuse Research
• U.S. Department of Justice Drug Use Forecasting Study
• Anecdotal evidence from parents, teachers, judges, and others.

Mr. Juaristi described highlights of A.B. 181:

• Section 2 provided for an internal state board within the Department of Human Resources to coordinate the services between mental health and drug abuse and between the Division of Child and Family Services, Mental Health and Retardation Division, and others. The intent had been to improve the dual diagnosis process that had taken place among young people.

• Section 3 allowed for the drug treatment providers in the state to apply for funding for residential, outpatient evaluation, transitional housing, and start up costs. Approximately $2.7 million had been appropriated through the bill.

• Section 4 required a reporting mechanism for accountability of funds provided by the bill.

• Section 5 established a commission to create a standard report card that identified at least four key indicators of the level of adolescent substance abuse. The report card would provide a constant measurement of focus from year to year. The section would also provide publicity for those key indicators to make the public better educated about the need for additional drug treatment services in the state.
• Section 6 provided definitions.

• Section 7 moved the Bureau of Alcohol and Drug Abuse (BADA) from the Department of Employment Training and Rehabilitation (DETR) to the Department of Human Resources (DHR). The move provided the advantage of having BADA within the DHR where most of the human resource divisions in the state were located. The intent also had been to reshape drug abuse as a health issue, not an employment issue.

• Section 8 allowed for gifts and grants to BADA to be accepted and placed in a fund for treatment services. The language of the section would be modified.

• Section 11 began the appropriation. The first would be $158,400 for three pilot projects in Family Resource Centers. The 41 centers in the state had endorsed A.B. 181.

Mr. Juaristi remarked the centers had seen those families and children on a daily basis and wanted to be able to provide help or have the opportunity to refer them to the appropriate service agency. Section 11 would set up the three pilot projects to begin the process which if successful could be expanded in the future.

Chairman Freeman asked if there had not been a place to refer children if they were picked up. Mr. Juaristi answered there had been certain referrals, but it was the hope of the bill's sponsors the Family Resource Centers would be able to provide more low level intervention services; something more than just a referral. Mrs. Freeman said she liked that approach. She also commented she had always wondered why BADA had been located within DETR; it had not made sense.

• Section 12 was the appropriation; $696,000 for residential treatment, $1.2 million for outpatient treatment, $52,500 for comprehensive evaluations, and $337,500 for transitional housing. An outline of exactly how the money would be used would be made available.

• Section 13 appropriated $184,390 from the state general fund for the accountability process, to make sure funds had been spent as defined.

• Section 14 provided $25,000 for a study to determine the effect of those funds on drug treatment of young people.

• Section 15 established the Family Resource Centers pilot projects.

• Section 16 provided the same language as previously existed.

Assemblywoman Gibbons asked where the Family Resource Centers to be established under Section 15 would be located. Mr. Juaristi said one would be located in southern Nevada, one in northern Nevada, probably Washoe County, and one in rural Nevada, the most logical locale would be Elko. He said however, the site would not arbitrarily be chosen, the centers had to apply through a request for proposal process. Additionally, the philosophy of Family Resource Centers (FRCs) had been they operated from the ground up rather than from the top down. Some FRCs might not want the pilot project and instead decide to devote their resources to another activity. The opportunity to apply would be given only to those who desired the activity and would be on a competitive basis.

A discussion ensued regarding statistics on the percentage of teens that had tried drugs and/or alcohol. Mr. Juaristi said the institute's figures had been on the conservative side for several reasons. However, the results of the 1997 Nevada Youth Risk Behavior Survey had shown 32 percent had five or more drinks in the prior 30 days. About 6 percent used cocaine or crack, 10 percent used marijuana on school property, and 25 percent used marijuana in the same period; the percentages applied to all adolescents, not just a specific age.

The Maryland study showed 51 percent of females tested positive for marijuana at time of arrest. Nevada judges had estimated approximately 41 percent of juvenile detainees had drug related problems. Ms. Gibbons referred to a report she had received regarding Washoe County which indicated a 78 percent figure of drug abuse among teens. Mr. Juaristi admitted the figures were wide ranging and had been the reason for his conservative estimate.

Assemblywoman Buckley said she had seen a memo stating BADA would take no position on the bill; however, there also had been a 15-page memo questioning everything Mr. Juaristi had presented. Mr. Juaristi responded by quoting Norman Swarzkopf, "Bovine scatology!" He added the memo might have concerned him 5 years ago, but since then he had learned that change was difficult, especially when one was the subject of it. The intent of the bill's sponsors was to ensure a lower fiscal note as well as to step into the project slowly; to provide conservative numbers. The sheer volume of people who had come out in support of the legislation, including a unanimous vote by all the drug treatment providers in Nevada, spoke to the need, in addition to all the studies, surveys, and sources quoted above. The bill architects' information had not been confined to the BADA database, they had sought out as much information and testimony as they could from people who dealt with those children and families on a day-to-day basis and done the very best they could to produce viable data.

Assemblywoman Evans stated Mr. Juaristi had done all the empirical work and that was where the evaluation should be made. During the Interim Committee on Juvenile Justice there had been witnesses, letters, e-mail, and phone calls critical of BADA. Many suggested the agency had not received the attention it deserved and would be better placed among other human service agencies. The idea of relocating BADA was not new and in fact had been the subject of discussion at the time of reorganization in the early 1990s. It had not been given enough attention at the time, but there had been interest then and very good arguments in favor of moving BADA to human services. Now there were no good arguments or justification for leaving BADA where it had been, particularly since there had been so many questions about its effectiveness and accountability. One of the strengths of the bill had been the accountability measures that needed to be put into any program for public monies.

Assemblywoman Leslie disclosed she was a volunteer member of the northern policy board of the Nevada Institute for Children and had participated in the study. She also worked for one of the groups who would be testifying, Join Together Northern Nevada, but "Join Together" would not be eligible for any of the funds provided by A.B. 181 and she would not benefit should the bill be approved. Further, she also worked as a consultant with Family Resource Centers; however, the money that would go to FRC would not go to her. Therefore, she intended to fully participate and vote on the matter. Ms. Leslie asked Assemblywoman Evans how she envisioned the move for BADA to the Department of Human Resources (DHR); would it be its own division, part of another division, or under Director of Human Resources Charlotte Crawford. Ms. Evans replied often in the legislature matters were assigned to Ms. Crawford simply because she had done an outstanding job and could handle anything given to her. As a practical matter however, it would be better if BADA was attached to one of the divisions, principally because of the support services that went with a program. A strong argument could be made for placing it in the health division, but that would be something for the legislature to determine. Alcohol and drug abuse was a public health matter.

Ms. Leslie commented in many states the substance abuse division had been located in the mental health division, and wondered if that would be an option. Ms. Evans said, "Yes," although she preferred the health division.

Chairman Freeman expressed the issue of accountability was of major importance since hearing from the legislative auditor. It was something that had to be emphasized more in the future than had been done in the past.

Robert H. Johnston identified himself as Acting Chief, Bureau of Alcohol and Drug Abuse. He stated A.B. 181 had not been developed by the Bureau of Alcohol and Drug Abuse; had it been a BADA initiative its ideas would have been incorporated in the annual executive budget and submitted to the governor. BADA held no position on the bill, as stated in Mr. Johnston's written testimony (EXHIBIT D). However, on February 19, 1999, he delivered to Assemblywoman Jan Evans a document (EXHIBIT E) related to A.B. 181

Mr. Johnston, pursuant to Ms. Evans request, had provided the committee with information on revenue to BADA and how it was allocated (page 2, EXHIBIT D) and money that came into the state from other entities that looked at substance abuse treatment and prevention in Nevada (page 3, EXHIBIT D). He stated the director of BADA had informed him the governor preferred BADA not move to the Department of Human Resources at that time, due to issues of fiscal impact that had to be evaluated.

Mr. Johnston questioned the number of 16,000 Nevada children in need of services, as stated in Mr. Juaristi's study (EXHIBIT C). In trying to determine from where the number had come, it appeared that data had come from BADA's adult needs assessment. Mr. Johnston then contacted Judy Caulder, Allen Bible Study for Applied Research, University of Nevada Reno (UNR), to determine if adult data could be applied to adolescents. She said it could not. That did not mean there had not been a need greater than the present service capacity, Mr. Johnston said.

In 1998, approximately 701 adolescents received substance abuse treatment in Nevada. Over 27,000 Nevada residents received prevention services, at least 70 percent were focused on adolescents. Looking at the number in the report (EXHIBIT C) of about 750 children who needed treatment, Mr. Johnston felt there would be the ability to provide treatment without a major fiscal impact.

Mr. Juaristi said what his group had looked at in their study (EXHIBIT C) had been unmet need, not need already provided. He reiterated their numbers had been conservative. The study provided at UNR actually used the figures for adults and the Institute for Children had used those as a proxy. Many people had argued unmet need for adolescents had actually been higher than for adults. What had then been done, and not considered in Mr. Johnston's remarks, was to augment and corroborate the data with the various reports and studies referenced above. He applauded BADA's service of 750 children, however believed the greater need had been well known and documented. Mr. Juaristi referred to a follow up study that Ms. Caulder, UNR, had done in which she, too, had used the adult figures as a proxy for the number of juveniles.

Assemblywoman Leslie commented she was appalled by the response from Mr. Johnston on behalf of BADA. "It was one of the worst responses by a state agency I have ever seen. The Committee on Health and Human Services would be hearing from many programs that would testify to the need." She did address one statement Mr. Johnston made about prevention, on page 2 of EXHIBIT E, where over 27,000 Nevada residents received prevention services. Many of the services were recreational-based; chess programs at school, for instance. It should not be misconstrued the treatment needs of the children had been addressed because recreational-based services had been provided.

In rebuttal, Mr. Johnson said he was sorry Ms. Leslie felt as she had expressed. One of the things that had to be examined in terms of prevention, intervention, and treatment was the continuum of care. One of BADA's prevention goals had been to delay the initial use of substances, which was the reason the programs were in place.

Assemblywoman Buckley asked how many adolescents Mr. Johnston felt in need of services. Mr. Johnston said he had done a survey of all of BADA's adolescent programs to determine the number of people still on the waiting list; he found 17 young people waiting for care. Other areas in the state where people had not been accessing services would need to be considered to determine what needed to be provided. He felt Mr. Juaristi had looked at the 5 percent who would have accessed treatment if it had been available, and believed he and Mr. Juaristi would be able to work together to determine the need from the estimated figures presented.

Mr. Juaristi commented he had seen the waiting list compiled by BADA. He had also spoken to some of the providers and discovered some had not kept a waiting list. Other providers indicated when a young person needed treatment they had actually "stolen a bed" from what had been assigned as an adult bed.

There had been that constant competition and friction between the two groups.

Still other providers reported people had simply stopped coming in for treatment because it had been too difficult to get in. The true testimony about the need had come from the providers and the Family Resource Centers, the people who had seen the children on a daily basis. Many of those children had not appeared on a BADA database because they had never been through a treatment program. Mr. Juaristi referred to a conversation he had with Dr. Curley Kurlinski who said he had seen so many teens come in with babies who had also been addicted to drugs, but they had never been through a treatment program; no one had ever seen them. "To say that some database somewhere does not account for these kids, does not mean these kids do not exist. We ought to realize that."

Assemblywoman Von Tobel asked Mr. Juaristi to provide at later date new figures that addressed the youth need, since the numbers on page 8 of EXHIBIT C had been derived using the adult numbers. Also, she found it hard to believe treatment facilities had not kept a waiting list, particularly a facility like WestCare who had been in the business of treating adolescents. Mr. Juaristi acknowledged some facilities did keep waiting lists, but not all. Also, because of the juggling done at some facilities by taking adult beds for juveniles, the adult waiting list had gone up. He also explained the means he had used for arriving at the youth need number by using the adult proxy. One of the ways his group had tried to compensate for that had been to use a 5 percent figure. They had used a proxy of the number of adults who had sought services, applied that for the children but determined only 5 percent of that number would actually seek services. That evidence was then corroborated as detailed earlier.

Mr. Johnston clarified earlier testimony regarding waiting list practices. Waiting lists were solely for substance abuse treatment. There were no waiting lists for prevention programs or intervention services.

Gerald Canning identified himself as Vice President of Sierra Pacific Power, the Chairman of Join Together Northern Nevada, and the father of a child with a substance abuse problem. He became involved with Join Together Northern Nevada as a result of what he and his wife had learned when they faced their daughter's problems. What they found was even if one had the means to pay for substance abuse treatment, timely treatment was impossible to obtain in this state. There had not been enough facilities available. They reached the stage of having to choose between Caliente or something outside the state.

Chairman Freeman asked if that were true in the private facilities. Mr. Canning said there were only three facilities in northern Nevada that treated teenagers.

The alternative to treatment, facilities for punishment and incarceration, were also over-crowded, Mr. Canning reported. The result had been no consequences for substance abuse until the collateral problems became severe. A great number of crimes had been overlooked by the police simply because there had been no place to put the offenders. He added his remarks had not been intended to be critical of the people in the justice system or the treatment facilities staff; the majority were overworked and underpaid but truly dedicated to helping kids.

Mr. Canning provided EXHIBIT F, and stated Join Together Northern Nevada (JTNN) had been created as a community partnership to find ways to be part of the solution in the war on substance abuse. It had been composed of a unique combination of people who worked with children as well as businessmen who had been looking for practical solutions. JTNN's priorities had been:

• Development of the organizational infrastructure to serve as a centralized clearinghouse of information and activities regarding substance abuse prevention and treatment programs serving Northern Nevada.

• Publication of an annual report card to document the status of substance abuse in Northern Nevada.

• Creation of an advocacy team and work-plan to educate the public about the need and efficacy of affordable, accessible treatment and prevention programs.

• Development of an implementation plan for a centralized assessment center to combine initial client assessment functions at one location and to divert existing assessment resources to treatment.

• Development of a strategic plan with specific goals and objectives in terms of coordination and expansion of prevention programs, and impacting specific substances use/abuse in targeted populations, especially youth.

• Continual search and monitoring of federal, state, and local government and private funding sources for JTNN priority areas.

Mr. Canning stated advocacy, because of the current legislative session, had been the top priority. Over the past 18 months JTNN had educated itself on issues and problems associated with substance abuse, had presentations from state and university agencies, and reviewed the research from BADA. The key findings had been:

The problem:

• In Washoe County, 3,000 teens needed substance abuse treatment; statewide, the need rose to 16,000 teens.

• Between 150 and 600 adolescents in Washoe County who needed treatment would seek treatment if it were available.

• In northern Nevada substance abuse treatment sources for adolescents totaled 33 residential beds, 27 day treatment beds, and 54 outpatient slots.

• BADA statistics on admissions to public programs indicated 536 adolescents received treatment in 1998. A conservative estimate of 275 teens, who would have taken treatment if available, went unserved in 1998.

• Nevada ranked 43 in the nation in allocation of funds for treatment services and 47 in funding for prevention.

Current Approach:

• Intensive intervention and juvenile drug court help.
• Locking up children has had little measurable success.
• Children's incarceration facilities were overcrowded and new facilities costly.
• Continuation of existing procedures with the expectation of different results was illogical.

The Solution:

• Adolescent treatment worked.
• Teens post-treatment relationships with parents and peers improved.
• Post-treatment substance use declined dramatically.
• Desire to drop out of school declined from 45 percent to 16 percent.
• Arrest rate dropped from 64 percent to 24 percent.
• School grades improved substantially.
• School absences dropped from 71 percent to 4 percent.

In conclusion, Mr. Canning strongly supported A.B. 181 as a balanced state solution which had addressed all facets a program needed to ensure success. Finally, however, Mr. Canning had addressed the Committee on Health and Human Services as a parent. The drug problem among adolescents was pervasive. He said both his children had assured him they could easily obtain drugs at (Galena High) school, from a sort of "lunch wagon" van that arrived every day at noon. Middle-manager-co-workers of Mr. Canning had approached him admitting they too had similar problems with their children; they had been afraid to admit it, had not known where to turn, and believed it would reflect badly on them to admit they had the problem in their own homes. Those problems did not happen to good parents; unfortunately the problem had happened in homes of every stripe and socio-economic level. The time had come to try a new approach; the children were our future.

Vilius Paskevicius identified himself as Program Administrator for the Economic Opportunity Board of Clark County, Residential and Outpatient Treatment Center located in Las Vegas. He also was president of the Nevada Association of Alcohol and Drug Abuse Program (NASADAP) and secretary of the Nevada Association for Addiction Counselors (NAAC). He provided written testimony and supporting documentation (EXHIBIT G) which stated in part:

• He and the organizations mentioned above strongly supported enactment of A.B. 181.

• The latest studies had shown an immediate need for adolescent residential and outpatient treatment.

• The adolescent population of drug abusers had been getting younger, smarter, harder to control, and more difficult to help.

• Adolescents were often faced with negative role models excusing their own abuse.

• There had been shown to be a genetic predisposition for addiction.

• Children of present adolescent drug abusers would one day seek treatment.

• The waiting list at his facility had been over 3 months long.

NASADAP's policy agenda for the 1999 Legislative Session, provided on pages 3 and 4 of EXHIBIT G, stated in part:

• NASADAP supported the move of BADA from DETR to the Department of Human Resources (DHR).

• The move would enhance the ability of substance abuse counselors to work collaboratively with the many divisions of DHR (Child and Family Services, Health, Mental Health and Mental Retardation, and others).

• Elevation of BADA to a division level would recognize the severity of Nevada's substance abuse problem.

Denise Everett, Chair of the Commission on Substance Abuse, Education, Prevention, Enforcement, and Treatment and Executive Director at SageWind, Reno, a treatment center for adolescents testified. Her field experience had shown there were many more adolescents who needed drug and alcohol services than there were services available. It had been especially true for low-income children and children involved with the juvenile justice system. There had also been a lack of services for middle-class children and children of the working poor who had not had substance abuse insurance benefits or could not find the services.

SageWind had been one of the few adolescent providers in northern Nevada for 22 years. For many years SageWind had eight beds for female teens only but had been asked frequently to acquire beds for boys. Funding had been found in 1997 for five beds for males, and those 13 beds had been filled in a few weeks. Last summer SageWind had moved to a new 15,000 square foot former monastery in Reno where 19 beds had been filled in one week. From August through December 1998 the waiting list for the transitional housing program had averaged seven children. It had been SageWind's desire not to keep children waiting for services, therefore, the children on their list had been placed in a lower level of care or been referred to other facilities. Sometimes parents of those children had not wanted to be referred so they disappeared and there had been no way to track them. Other times, when parents had called to ask about services and were told no beds were then available, they hung up and were not heard from again. Thus, a waiting list had not been an effective way to judge the need in the state.

Similarly, with prevention programs, for several years SageWind had a project primarily in high-risk schools in Washoe County School District. Research showed long-term consistent prevention projects had worked best. SageWind had worked in those schools for an average of 3 years in grades K through 6. Many other schools in the district had asked counselors constantly for a similar program. SageWind had not had enough counselors or funding to fill those demands. Subsequently Washoe County recognized the value of the program and had taken it over. In the meantime, SageWind began another intervention project to work with children in grades 5 through 8.

SageWind had found when they referred children to other facilities, like New Frontier in Fallon or the for-profit private entities which occasionally had a scholarship bed available, they had been full.

Chairman Freeman asked where was the money obtained for those scholarship beds. Ms. Everett said the for-profit facilities might have used a percentage of their profit to provide service for a child who had no resources.

Often the act of getting an evaluation or assessment for substance abuse problems had been an arduous process. SageWind had two full-time intake counselors and stayed about 3 weeks behind from the time a client had called until they were seen.

The majority of SageWind's budget was grants or contracts, followed by donations and at a distant third insurance and private party payments. Most clients' parents had no insurance or financial resources to pay for substance abuse treatment for their child. It had been very difficult to find adequate funding at least for the past 4 years in which Ms. Everett had been employed there. SageWind had never received the full amount requested from any granting source. No one had wanted to fund assessment, after-care, or alumni groups. Any improvements in quality or quantity of services had to be well thought out in advance and financing found through private foundations, donations, or other resources. Substance abuse treatment for adolescents had definitely been under-funded.

Ms. Everett stated it made infinite sense to elevate BADA from a bureau to a division and move it from DETR to DHR. Many divisions in DHR frequently shared the same clients with BADA, and substance abuse had been more of a public health issue than a physical rehabilitation or employment issue, therefore, the move appeared very reasonable. If all those divisions were housed in the same department, service delivery to clients would be streamlined, resources maximized, and communication enhanced. Also, since budget issues had been a major concern, the figures she had seen would appear to make the elevation and move of BADA a financial win for the state.

Ms. Everett felt the pilot project to provide the Family Resource Centers with a certified drug and alcohol counselor was a very reasonable approach to the complex problems the centers faced. Substance abuse traveled through all social ills, from child abuse to criminal activity to health problems. Certified counselors would support the Family Resource Centers in those issues.

She stated emphatically when someone said a child had received services at a BADA-funded program, it had not meant the Bureau of Alcohol and Drug Abuse had paid 100 percent of the child's treatment. SageWind was a BADA-funded treatment program and only 30 percent of its budget came from BADA.

Finally, Ms. Everett said for many years SageWind had been relatively flat-funded by BADA. She had researched how much money the state had spent on substance abuse treatment, intervention, and prevention since 1992 and spending had decreased annually.

Assemblywoman Gibbons commented, since 1992 teenage drug use had doubled. Ms. Everett reiterated Nevada was the fastest growing state in the nation.

Chairman Freeman asked the average length of stay and cost of treating a child at SageWind. Ms. Everett replied it depended upon the level of service—SageWind had transitional housing, day treatment, intensive outpatient, outpatient and aftercare. Generally, the cost had been $80 per day for day treatment and $48 for transitional housing. It had been substantially less than for-profit treatment centers or incarceration.

Terence Sherbondy identified himself as Center Director, Sparks Family Resource Center, and urged support of A.B. 181. In his prepared testimony (EXHIBIT H) Mr. Sherbondy stated, in part:

• Family Resource Centers would effectively help coordinate and implement services related to the prevention of substance abuse and related problems.

• Sparks Family Resource Center, and other state and county agencies, had developed and implemented an Early Intervention Substance Abuse Prevention Program targeted at grades 5-8.

• The program began in December 1998 with seven students participating in the twice-per-week, 8-week program. Referrals had come from schools and parents. Four of the original seven students completed the program; one dropped out, and two missed at least one session. Two students had requested to continue in the program.

• Five students had signed up for the next series.

• Participants would be tracked for 3 years following participation to determine the impact of the program on future academic, social, and family experiences.

• Family Resource Centers had a close working relationship with schools, businesses, private citizens, and families. The centers had become part of the state's human service landscape.

• Passage of A.B. 181 would help continue and expand the Early Intervention Program to other schools and neighborhoods.

• Family Resource Centers fell under the direction of the Department of Human Resources. Placing the Bureau of Alcohol and Drug Abuse under the umbrella of the DHR would enhance coordination of services within one department and strengthen the service link between agencies.

Chairman Freeman raised the issue of reduced funding for Family Resource Centers and asked someone from the state to address that concern.

Janice Wright, Deputy Administrator, Division of Health Care Financing and Policy (HCFP), stated there was a reduced amount of appropriation available for those programs in the executive budget but had no specifics at the time.

Mrs. Freeman asked how the Family Resource Centers had grown in the last 4 years, the level of use, how many children served, and what changes would be made as a result of a cut in the budget. Ms. Wright said she would provide that information.

Chairman Freeman thanked the participants for their testimony and said they would get another chance to voice support when the bill went before the Committee on Ways and Means.

Mrs. Freeman asked for testimony in opposition to A.B. 181.

Richard Steinberg identified himself as President and CEO of WestCare and stated WestCare was partially in favor of A.B. 181. However, he expressed concerns about the overall bill. He applauded the efforts of Vince Juaristi and others who had testified for their tremendous efforts in the area.

Mr. Steinberg said WestCare had a significantly large youth and family services center in Las Vegas with 80 beds, 60 day treatment slots, and at times they had waiting lists. They had developed systems in conjunction with BADA and others to provide a network of moving people through formerly bogged-down areas. He said he had been a major critic of BADA for years. In fairness, however, some of the questions asked about BADA, the beds, and the people serviced which were not BADA-funded had probably restricted Mr. Johnston in his responses. Mr. Steinberg said his concern had been about BADA being buried "down in the system." His greater concern had been having BADA put back to the Department of Human Resources where it had been buried before and not able to the same level of work. That needed to be carefully considered. About suggestions BADA be put under mental health, he said in states where that had happened it produced a negative impact on services for children and adults. The Federal Government had been working on the issue because of the breakdown and the way it had been done and had seen a distinct need to keep separate substance abuse and mental health.

Several things had not been addressed in A.B. 181. One, 78 percent of adult prison population had been arrested for some part of a problem with drug or alcohol abuse. If that was put back in the Department of Human Resources it would not be addressed. Currently with BADA in DETR, in the rehab area, people received additional services and linkages through a variety of areas. Those things needed to be addressed not buried. If a move was to be made in the state concerning BADA, it should not be called BADA and put under a department. The state should do what California and other states had done and make BADA its own department. Mr. Steinberg cited work done by the Drug Commission in 1989 when the same issue was raised. Since that time the issue had been watered down and the legislature had not had a chance to monitor it closely. Second, a lot of the money appropriated under A.B. 181 would go for infrastructure and would not necessarily get to services for children.

Mr. Steinberg expressed concern about the fiscal impact. A.B. 181 created another infrastructure, another board to be established, but had not addressed other issues facing the state that were also very costly to the taxpayer and were being overlooked. He was not in opposition to the good parts of the bill, but there were major voids in the overall drug and alcohol impact in the state.

Chairman Freeman asked if Mr. Steinberg knew of states that had a model program. He responded the most recent program he had seen that had done well was California where alcohol and drugs had its own department. The top person in the department sat as a cabinet member to the governor and could work at a top level with law enforcement, education, and mental health.

In the corrections area, there would be close to 10,000 treatment beds on line within the prison system by the end of the next 3 years. In the past the state has had knee-jerk reactions to problems; it needed to examine and address the overall picture.

Mrs. Freeman asked how California funded its department. Mr. Steinberg said the same procedures were in place as in Nevada and all the other states: block grant systems, state and federal money, and combinations.

Assemblywoman Leslie asked what percentage of clients had been dually-diagnosed with mental health and substance abuse problems. Mr. Steinberg felt it had been 20 percent or less, due to the intake procedures in place at WestCare. He doubted the 60 percent figure testified earlier, and believed it had to do with the reluctance of workers and others to label clients. For instance, labeling a child a drug/alcohol abuser had other connotations that followed the child throughout their growth whether or not they had recovered.

Ms. Leslie asked to hear from other providers about the percentages, as she felt 20 percent was low. She asked if he would be in favor of BADA being its own division within a department. Mr. Steinberg said his concern had been that when BADA was there previously it had been a "real stepchild." He agreed however that BADA at a division level would be better than nothing. He would like to see it stay where it was and not moved to Department of Human Resources.

Chairman Freeman suggested Mr. Steinberg speak to Assemblywoman Evans again. He agreed to do that.

Mrs. Freeman said the bill had to go to the Committee on Ways and Means.

ASSEMBLYWOMAN GIBBONS MOVED TO DO PASS AND REREFER TO THE COMMITTEE ON WAYS AND MEANS.

VICE-CHAIRMAN KOIVISTO SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

**********

Mrs. Freeman told the participants they would be hearing from the Committee on Ways and Means and wished them all the luck in the world.

Chairman Freeman opened the work session on A.B. 4.

Stacey Ziegler, Assistant Director of Great Basin Primary Care Association, presented a letter from Richard J. Skelskey, Ph.D., President of Great Basin Primary Care Association, dated February 24, 1999, (EXHIBIT I), addressed to Chairman Vivian Freeman in support of A.B. 4, A.B. 5, and A.B. 6.

Jon Sasser identified himself as a statewide advocacy coordinator. He said the bill would eliminate the assets test in the Children's Hospital Assurance Program (CHAP) which had been a portion of the state Medicaid program. The assets test had been one of the difficulties in terms of interaction or lack of seamlessness between the Check-Up program and the CHAP program. Chairman Freeman had asked him to give an opinion on a fiscal note. He stated Janice Wright had given a fiscal note he had questioned. She had stated it would cost $5 million a year in extra funds to CHAP which would be reduced by $2 million a year because people would otherwise be eligible for Check-Up. She was, he said, still using some base figures for caseload for which he had no explanation. The figures seemed quite high compared to past figures of about 2 percent of the CHAP applicants being turned down for excess assets, but he had no further detailed explanation of how she achieved her caseload stats.

Janice Wright, Deputy Administrator of Health Care Financing and Policy (HCFP), stated she had worked with Mr. Sasser however there had been some miscommunication. At the last hearing on A.B. 4 there had been discussion regarding the fiscal impact and what she had tried to indicate was about a $3 million impact for the Medicaid program. It had not been well understood because of the difference between the Medicaid program and the Check-Up program. HCFP had been concerned with pregnant women as a new group not currently eligible for the Nevada Check-Up program. That was a difficult area to assess. HCFP had looked at the number of pregnant women turned down by the Medicaid program as a result of having excess assets. HCFP would have an amount close to that $3 million; however, it might be affected by the fact the two programs differed with respect to retroactivity. There would also be another aspect; the SOBRA Kick Payment (Sixth Omnibus Budget Reconciliation Act), in an amount of $5,267.65 per pregnant woman for pre and postnatal care. That would be an additional expense to the Medicaid program. Medicaid covered the pregnant women, the Nevada Check-Up covered only the children. Therefore, it would be expanded to cover a new group.

There would be some differences with respect to the state match amount that would have a slight impact. There had been a 50 percent match for the Medicaid program and 65 percent federal match for the Nevada Check-Up program. That would shift some of the burden.

Chairman Freeman said because there had been a significant fiscal note the bill would be rereferred to the Committee on Ways and Means.

ASSEMBLYWOMAN VON TOBEL MOVED TO DO PASS AND REREFER A.B. 4 TO THE COMMITTEE ON WAYS AND MEANS.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

**********

Chairman Freeman opened the work session on A.B. 5.

Chairman Freeman referred to the Work Session Document (EXHIBIT J) prepared by the Research Division, Legislative Counsel Bureau, which had included, as Attachment A (page 3), the proposed change for the amendment to A.B. 5, as followed:

• Line 1-2: Delete "Conduct a study to determine the feasibility of providing:"

Add "Provide:"

• Line 1-8: Delete "; and". Add "." after inclusive.

• Delete lines 1-9 through 2-2.

Bobbie Gang identified herself as representing the Nevada Women's Lobby, in place of Louise Bayard-de-Volo who had been slated to testify. She stated the Nevada Women's Lobby had presented the amendment language to A.B. 5 for consideration. The issue had been discussed for many years in legislative sessions and interim sessions and the time had come to make the decision to cover pregnant women.

(Note: Please refer to EXHIBIT I for letter from Richard J. Skelskey, Ph.D., President of the Great Basin Primary Care Association, dated February 24, 1999, to Chairman Vivian Freeman in which he had supported A.B. 5.)

ASSEMBLYWOMAN BUCKLEY MOVED TO AMEND AND DO PASS AND REREFER A.B. 5, WITH AMENDMENT BEING TO INSTITUTE AS SET FORTH IN THE WORK SESSION DOCUMENT.

Chairman Freeman mentioned several people had discussed with Governor Guinn's office the possibility of a Robert Wood Johnson grant to help provide for the program. She asked Ann Cory to provide an update.

Ann Cory identified herself as Interim Director of the Great Basin Primary Care Association, the lead agency for the Nevada Covering Kids Coalition. Her written testimony was provided as EXHIBIT K. The coalition had been comprised of 17 statewide organizations of public and private partnerships. In 1998, an application had been submitted and in December 1998, a site visit made by the Robert Wood Johnson review team. The coalition would resubmit the application for approximately $850,000 over 3 years. Her group would be working with a statewide coalition and three pilot projects to cover three major goal areas:

• Outreach—to find children and enroll them in Medicaid.

• Simplification--to simplify eligibility screening and enrollment processes.

• Coordination--of enrollment, screening, and outreach so private agencies would be able to assist the state in building on the activities the state had already undertaken. The program would not duplicate or supplant state efforts but would work with the state to enroll more children in Medicaid and Check-Up.

Ms. Cory said monthly meetings had been held with the northern, southern, and rural coalitions. Many of the activities would take place through the coalitions.

(Note: Please refer to EXHIBIT I for letter from Richard J. Skelskey, Ph.D., President of the Great Basin Primary Care Association, dated February 24, 1999, to Chairman Vivian Freeman in which he had supported A.B. 6.)

Chairman Freeman asked if A.B. 6 would go to the Committee on Ways and Means. Assemblywoman Buckley responded she believed it should go, because of the $99 cost for the application.

Ms. Buckley said the bill had to go to the Committee on Ways and Means. She felt it would be most effective to contract with an outside marketing agency, but it would be best to let the Committee on Ways and Means discuss it.

Mrs. Freeman asked Janice Wright if she had any figures to present. Ms. Wright said with the amendment and rereferral to the Committee on Ways and Means, HCFP would be able to present the information to them specifically for the amendment. Ms. Freeman asked Ms. Wright to provide the figures when she obtained them.

Assemblywoman Von Tobel said she had been in a Republican caucus with Governor Guinn who had pledged support for the Check-Up program. He would love to see the enrollment double to 10,000 or more children. He stressed there was not a cap on enrollment.

Chairman Freeman asked Ms. Von Tobel to advise the committee when she had something definite on the program from Governor Guinn, particularly since she and Ms. Buckley had been discussing the program for many months.

Assemblywoman Buckley asked to offer an amendment to require the Health Division to establish a marketing program for Nevada Check-Up. The number of children who had been enrolled had been extremely low. The amendment would put the issue squarely before the Committee on Ways and Means.

ASSEMBLYWOMAN BUCKLEY MOVED TO AMEND AND DO PASS AND REREFER A.B. 6 TO THE COMMITTEE ON WAYS AND MEANS WITH AN AMENDMENT TO INCLUDE A DIRECTIVE TO THE HEALTH CARE FINANCING DIVISION TO ESTABLISH A MARKETING PROGRAM FOR THE NEVADA CHECK-UP PROGRAM.

ASSEMBLYWOMAN VON TOBEL SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Jon Sasser, Statewide Advocacy Coordinator, stated he had been requested by Chairman Freeman to work with Janice Wright, Deputy Administrator, Health Care Financing and Policy, on the fiscal note Ms. Wright submitted previously, which Mr. Sasser felt was too high. Mr. Sasser provided "Comment on Fiscal Note to A.B. 139" (EXHIBIT L) which stated in part:

• Who would qualify for Medicaid under A.B. 139.

• There had been a 2-part test: The individual had to go through the process and found to be disabled under the Social Security Administration's (SSA) standards. The individual's assets could not be over the Social Security Income (SSI) eligibility limits of $2,000. The individual's income minus the earnings fell below the SSI limits.

• Who might meet that criteria: There were 11,652 adult disabled SSI recipients in Nevada who received Medicaid. If those individuals returned to work and kept their Medicaid, there would be no negative fiscal impact and might be a positive fiscal impact. The reason was some of those re-employed individuals might qualify for health insurance provided by their employers. Thereafter, Medicaid would be a "wrap-around" policy that provided personal care attendant or home health services as those might not be covered in their employer-plan, but the Medicaid coverage would cost less than the full range of coverage provided previously.

• For those 11,652 individuals, the fiscal impact would be nothing and in the long run save money.

• The 26,670 Social Security Disability Income (SSDI) recipients' benefits were higher than the $500 level for SSI benefits for an individual. They had not received Medicaid because they were over-income. If they went to work they would still be able to keep for a certain time their SSDI check. As long as they received the SSDI check they would not be eligible and not picked up under the program.

• If, 9 months later, they had stayed with the program they would be deemed to be employable by Social Security and would lose their SSDI check. They could still keep Medicare for 3 years which would pick up a large portion of their medical bills.

• The figures Ms. Wright had used had not taken into account the almost 4 years of Medicare coverage.

• In the entire United States, less than 38,000 SSDI recipients returned to work in the most recent reporting year. Less than 1 percent of U.S. citizens with a severe work disability resided in the State of Nevada. The SSA reported 86 people for training reimbursement in Nevada in 1997.

• Nevada received reimbursement from only 235 SSI and SSDI recipients combined who had been unable to return to work in 1997.

• According to Donny Loux, Director of the Community Based Waiver Program the only people who would participate would be those 86 individuals once they had exhausted their 9 months SSI eligibility.

In conclusion, Mr. Sasser believed the fiscal impact had not been nearly as high as Ms. Wright had projected. Further, there had been enough data compiled to believe the program might be funded by the Committee on Ways and Means.

Assemblywoman Gibbons asked about entitlement money. Janice Wright, Deputy Administrator, Health Care Financing and Policy (HCFP), responded affirmatively. Half of the funds would be provided by the Federal Government under Title XIX, half of the impact would be state general fund.

Janice Wright provided a spreadsheet (EXHIBIT M) which had set forth the estimated figures that had been discussed. HCFP had not been sure exactly what the population would actually be, therefore, the figures in EXHIBIT M provided a range of what the discussion had been about. She would look forward to working through the Committee on Ways and Means to clarify the numbers.

Mr. Sasser clarified the 86 individuals to whom he referred in his testimony and in Ms. Wright's spreadsheet would be the only ones who would cost the state any money. There would still be a tremendous benefit for individuals who sat at home on Medicaid to go back to work and continue to get Medicaid. He hoped many more would participate and improve their quality of life.

Chairman Freeman said that had been an important point. She felt it might be a good idea to send a letter of intent to the Committee on Ways and Means when A.B. 139 was rereferred to them.

Ms. Wright said the difficulty in determining the population spoken of earlier had to do with those aged individuals who would qualify .It had been difficult to find out how many of those who were currently working, and working up to that level, were going to be eligible. They were an additional group. They were called "aged" and thus qualified as disabled for SSI. HCFP had not been able to determine how many there were in the state.

Assemblywoman Buckley suggested she and Mrs. Freeman might go together to the Committee on Ways and Means on some of the bills, because both had worked on them for months on the Interim Committee. The bills had been so important she felt the message should be carried directly to Ways and Means. Mrs. Freeman concurred. She felt a letter of support from the committee should also be included along with all the letters of support received over the years.

ASSEMBLYWOMAN GIBBONS MOTIONED TO REREFER A.B. 139 TO THE COMMITTEE ON WAYS AND MEANS.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

**********

Chairman Freeman opened the work session on A.C.R. 12.

Chairman Freeman stated the resolution had been brought to the Interim Committee on Health Care by Winthrop Cashdollar, Nevada Health Care Association.

Marla Williams, Committee Policy Analyst, stated A.C.R. 12 had been a recommendation from the Health Care Committee, generated by former Assemblyman Close who had indicated there were individuals who could benefit from assisted living services if allowed to access the program through Medicaid. Mr. Cashdollar came before the committee and said his preference was not to provide funding to an unlicensed facility.

Janice Wright, Deputy Administrator, HCFP, said the resolution as proposed would expand the current Medicaid program and would have a fiscal impact. If amended HCFP requested it be referred to the Committee on Ways and Means.

Chairman Freeman expressed concern about unlicensed facilities and felt more discussion would be needed before action was taken.

With no further testimony, the Chairman adjourned the meeting at 3:30 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: