The Committee on Health and Human Services was called to order at 1:40 p.m., on Monday, April 26, 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. Sharron Angle

Ms. Merle Berman

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Mr. Wendell Williams

COMMITTEE MEMBERS ABSENT:

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Kathy Von Tobel

GUEST LEGISLATORS PRESENT:

Senator Valerie Wiener, District 3

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Note: A simultaneous videoconference was held in Room 4412 of the Grant Sawyer State Office Building, 555 East Washington Avenue, Las Vegas, Nevada.

Following roll call, Chairman Freeman opened the hearing on S.B. 117 and asked Senator Valerie Wiener to introduce her bill.

Senator Wiener, representing District 3, explained she introduced S.B. 117 because of her experiences with the Commission on Aging. She had been appointed to serve as the Senate's representative in 1997 and had become quite involved with the commission's activities. Her participation ranged from attending meetings to project development and working with the Silver Haired Forum. Her involvement had led her to appreciate the expertise and experience the members offered to enhance the State Division for Aging Services. When the commission lost several critical members because their terms had expired Ms. Wiener then realized the value of their input. It was that situation that caused her to want to find a way to continue to utilize past member's vast storehouse of knowledge to continue to benefit the commission.

S.B. 117 would allow former commission members and members of the general public with experience and knowledge about matters relating to older persons to participate in the subcommittee or on an advisory council. Those individuals would not be voting members and would receive only travel and per diem compensation for their services. No additional funds needed to be allocated to the Commission on Aging for occasional subcommittee or advisory council meetings.

Ms. Wiener emphasized maintaining a source of experienced advisors was critical to the commission. They were an invaluable asset to the State of Nevada in helping formulate the policies affecting senior citizens. She urged the committee's support for S.B. 117 for the contribution the members made.

Chairman Freeman relayed a concern expressed by one of her constituents about the composition of the Commission on Aging services that it was primarily state employees. Senator Wiener asked to have Bill Langley respond to her concern.

Bill Langley, community resource development unit manager, Division for Aging Services, identified himself and stated the commission was composed of 11 voting members and 4 nonvoting members. The nonvoting members were the chairperson who was Charlotte Crawford, director of the Department of Human Resources, Carla Sloan, administrator of the Division for Aging Services, Senator Valerie Wiener, and Assemblywoman Chris Giunchigliani.

Mr. Langley stated the Division for Aging Services supported the legislation as proposed. He explained every 2 years there were special subcommittees of the Commission on Aging formed to review the Older Americans Act Title III grant applications and make recommendations to the commission regarding grant funding awards. Additionally, periodically special commission subcommittees had undertaken special projects such as the November 16, 1998, Vision Conference for Senior Centers in Reno. Highlights of Mr. Langley's testimony, provided as Exhibit C, were as follows:

• Special subcommittees were a very important activity of the Commission on Aging, but it was often difficult to find a sufficient number of commissioners available to perform the special occasion work involved.

• S.B. 117 would solve the situation. It would authorize former commission members or members of the general public with specific expertise to serve on subcommittees and advisory committees. Those persons would not replace voting commissioners.

• The bill would allow compensation for travel and per diem to former retired Commission on Aging members who lived on fixed incomes, when their expertise was needed. They would not be compensated like committee members for daily service.

• There was minimal fiscal impact. No additional funds needed to be allocated for special subcommittee meetings. The reason was there were often absences of one or two commissioners at the quarterly meetings which would make funds that would have been paid to them available for future special subcommittee meetings.

• The division recognized that management oversight would be required to assure the commission's budget authority was not overspent. Those safeguards were already in place within fiscal services and community resource development units.

• The proposed legislation was the commission's solution to the periodic concern.

Assemblywoman Leslie asked how many members would be placed on the advisory commission, were there written guidelines and term limits. Mr. Langley replied there were no term limits. Special occasions such as the vision conference required special subcommittees involved in preparation activity, and the jobs of those subcommittee members would end when the occasion had ended. Presently the Title III-B social service grant activities were underway and the commission was using special subcommittees in northern and in southern Nevada to perform application reviews and process the potential grantees. Those activities involved 4 to 5 days plus the meeting itself. Other events might take 1 day or part of a day.

Ms. Leslie restated her question: How many people would sit on the subcommittee. Mr. Langley said it would be unique for each event; perhaps 1 to 4 people. Ms. Leslie asked what was the overwhelming need for the measure to be in statute if it was already being done informally. Mr. Langley said it was a lack of numbers available when the need arose.

Dr. John Yacenda, deputy director, Department of Human Resources, asked to respond to Ms. Leslie's question. The bill added the ability to create subcommittees to the existing commission. It allowed the commission to retain various members who because of their expertise had served well and were needed to serve on special subcommittees for future special events. The bill established a mechanism whereby the subcommittees would have official status and be compensated according to state per diem laws.

Ms. Leslie expressed discomfort about not knowing how many people would be appointed and other aspects and was not convinced it needed to be in law to accomplish the goal.

Senator Wiener stated the legislation was prompted as a result of an expert gerontologist who had served her full term and her service to the commission ended when her term did. There might be an occasion in the future when her expertise would be valuable. The bill would allow the commission to bring her in under a subcommittee or advisory committee.

Ms. Leslie acknowledged the value of such a person, however, there was value as well to turnover and new ideas.

Assemblyman Williams asked about the number of the members on the commission and Dr. Yacenda said there were 15. The governor appointed the 11 voting members, two nonvoting members were division heads as required by statute, and two nonvoting members were appointed by the legislature. There were term limits. Mr. Williams asked if those persons who had served could come back and work on subcommittees without the legislation. Dr. Yacenda said they could but would not be compensated.

A lengthy discussion ensued between Assemblyman Williams, Dr, Yacenda, Mr. Langley, and Senator Wiener, again trying to explain the duties of the subcommittee members and generally reiterating previous testimony. Mr. Williams wondered if with the subcommittee members participation a decision could be forced. Senator Wiener emphasized the member's job was to report back to the commission, not to make decisions. Mr. Williams concurred with Ms. Leslie that it was somewhat of a puzzlement why the legislation would be needed.

Assemblywoman Berman voiced support for S.B. 117 and believed it was important to have people who were previously involved continue to lend their expertise. The fiscal note was under $300 and for that small amount it should not be a financial hardship.

Chairman Freeman asked if the division would absorb that amount. Dr. Yacenda confirmed it would as part of the commission budget. He continued, in response to Mr. Williams earlier question, to explain the bill had grown out of the realization that the process was losing valuable knowledge. It was a bill that had come out of determining if a slight adjustment was made a better job could be done in representing the seniors and the issues facing older Nevadans.

Mr. Williams acknowledged the committee was one of policy not finances, and he believed anyone who served on the commission's subcommittees should be paid. The issue was policy, and how much input should someone have in a process who had not been appointed as a regular commissioner yet filled in for the commissioner. He wondered about replacing the commissioners who were not attending the meetings because if they had not attended the meetings they could be influenced by the information brought to them by the persons who were substituting for them. It was a question of policy.

Chairman Freeman asked if there were members who consistently had not been present at meetings. Dr. Yacenda said it varied depending upon what was going on, the time of the year, vacations, and so on.

Assemblyman Manendo noticed individuals in the committee room audience giving nonverbal indication that was contrary to what Dr. Yacenda had said. He invited those who wished to speak to do so.

Vice Chairman Koivisto asked how many people had to be at a commission meeting in order to vote on an issue. Dr. Yacenda said the quorum was 6 of the voting members. Ms. Koivisto then asked if enough people had been present for a quorum. Also, if the member terms began and ended at the same time. Dr. Yacenda advised there had been enough people present at the meetings to vote. The term was for 2 years with a 2 year extension at the approval of the governor, and the terms were staggered.

Next to speak was Virginia Cain, president, Nevada Silver Haired Legislative Forum. She stated the organization was formed under Nevada Revised Statutes (NRS) 489. There were 21 members appointed by the governor and four other members who belonged to the National Silver Haired Congress. She explained the forum's role was to survey the needs of the aging population in the State of Nevada. She expressed support for S.B. 117 because the state's growing senior population was not being adequately served. Very little legislation had been prepared in the 1999 session that would benefit the aging senior citizens of Nevada. There were serious problems. The role of the Commission for Aging Services would be to assist in the implementation of the work done by other services. What was needed was an active aging commission to address the basic needs. Examples were long-term care, assistance with Medicaid, transportation where none was available, and particularly the lack of services in small counties. It was imperative to understand the needs of the entire state. If there were only two or four persons on the commission all from one section of the state, they could not have the same understanding of conditions in other sections of the state.

In closing, Ms. Cain urged support for S.B. 117 so the Division for Aging could be assisted with additional expertise from persons committed to the purpose.

John Amundsen, a member of the Nevada Silver Haired Legislative Forum, expressed views similar to Ms. Cain's. He added for the minimal cost involved the State of Nevada and its senior population would benefit greatly from the vast knowledge and expertise of individuals who had worked on senior-related issues for many years.

Rosemary Smith, a member of the capital district's Silver Haired Legislative Forum, urged support for S.B. 117.

Chairman Freeman asked Ms. Cain if she and the others who attended the meetings received a per diem payment. Ms. Cain responded that was one of the issues to be discussed with the governor. The Silver Haired Legislative Forum had been operating without funding. The statute that created the forum provided a $5,000 operating fund. The forum's organizers set up the entire organization, developed bylaws, procedures, and goals. They also had to determine how they would travel to all parts of the state to hold hearings with senior citizens without funding. Ms. Cain said they attempted to obtain funds from foundations; however, were turned away because the forum represented a government agency. However, they raised approximately $16,000 through private funding. All the forum had accomplished to date was due to the talent and dedication of those volunteers appointed by the governor. In order to strengthen that group they needed funding in the future.

Chairman Freeman asked if any federal funding was available. Ms. Cain responded "No, our chief source of support from the start came from the National Committee for the Preservation of Social Security and Medicare. A nongovernmental agency supported by private funds." Ms. Cain explained she had been on the leadership forum of the group and had been able to obtain seed money. With the $1,000 seed money they had been able to hold an organizational meeting. All meetings had been held in southern Nevada because it had been less expensive to transport 6 individuals from the north to the south than to bring 21 individuals from the south to the north. All of the forum's stationery, mailers, computer services, and so on had come from contributions.

Mrs. Freeman asked what Ms. Cain's group would request from the governor at their upcoming meeting. Ms. Cain replied they wanted to have the forum that had been formed as an arm to assist the aging population of Nevada to continue under statute and to be funded. Further, they wanted to discuss the legislation related to seniors they felt needed to be supported.

Assemblyman Williams asked Senator Wiener about geographical representation being maintained when an advisory member was called in to substitute for a commissioner. Senator Wiener responded it was the chairman who appointed the members. When the bill was drafted no language had been included to specify the appointment should be made with geographical criteria. Mr. Williams said the statute specified the governor must appoint members whose geographical location ensured the entire state would be represented. However, when the commission chairman made substitutions to fill gaps due to absenteeism he had the ability to select someone from anywhere in the state and there was no assurance an individual from the same county as the regular member would be called in. Mr. Williams believed if it was important enough to put into statute that the governor had to make appointments based on geographical criteria, then the commission chairman should likewise be mandated to use the same criteria when making substitutions.

Mr. Williams further pointed out the statute allowed for two 2 year terms and a reappointment for a third term, therefore, nothing precluded an individual who had proved to be valuable over the years from serving as many as 6 years. It was more logical to simply reappoint those people who had served as commissioners than to have substitutes. He asked if members who had been absent had given prior notice. Also, what would happen if a substitute member was called in and then the regular member came after all, would both then expect payment.

To the continuing barrage of questions, Dr. Yacenda commented good-naturedly how pleased he was to come before the committee again. He had been on the senate side until now and had missed them. He got a laugh. In response to Mr. Williams, he said commissioners could be appointed for a second term but no more than two terms. Next, the advisory subcommittees being created by the legislation were not intended to be represented at commission meetings with the exception perhaps, that one person might be there to make a report on the subcommittee's activities. But that would not necessarily hold either since a report could simply be submitted in written form. He agreed with Mr. Williams' point about geographical representation and would welcome language either in the bill or by letter of intent that all subcommittee appointments met geographical and demographical criteria. It was a very important aspect in making the entire concept work.

Chairman Freeman asked Senator Wiener if she would like to amend S.B. 117 accordingly or alternately have a letter of intent. She said she agreed with the idea and would like to see the bill amended.

Mr. Williams had one final question. He asked about an amendment that would extend the term limit cap for commissioners rather than have the advisory members serve as substitutes. Senator Wiener said part of the reason the sub or advisory committee was so important was because the breadth and scope of the commission's work had increased and people could only be stretched so far. With former commissioners serving in sub or advisory capacities they could bring their expertise to the problem or issue for a one-shot situation. In other words, they could supplement what the commission was doing on a regular basis.

Mr. Williams asked whether the amount of work the commissioners had in their current duties caused them to be unable to perform additional tasks. Senator Wiener said it was difficult when they only met quarterly to do other things in between; however, an advisory person would be able to perform those other tasks.

Mr. Williams then asked if any law prevented the chairman of the commission from calling people who had expertise and had worked previously to sit on future subcommittees or serve in an advisory capacity. Mr. Langley said he was unaware of any law preventing that. Mr. Williams asked if it could be done without the need for the bill. Mr. Langley answered there would be no compensation for those individuals.

Chairman Freeman recommended Senator Wiener work with Mr. Williams, Ms. Leslie, and Ms. Williams on an amendment and bring it back to the committee. The parties agreed to do that.

Mrs. Freeman then closed the hearing on S.B. 117 and opened the hearing on S.B. 197.

Senator Wiener, sponsor of S.B. 197, provided background on the bill that in its original form included a great deal more including a $600,000 fiscal note. A team of interested professionals, state agency representatives, and Senator Wiener then worked to pare down the bill to its present form. She was proud of what they had accomplished with creative uses of existing and new resources with a zero fiscal note.

The tragedy of fetal alcohol syndrome (FAS) had been well stated in the preamble of the bill. The statistics indicated the damage that health crisis imposed on everyone in the State of Nevada. There was a distinct tie between juvenile crime and FAS. It had been estimated 50 to 60 percent of youths involved in the juvenile justice system were FAS babies. The cost to taxpayers was staggering in terms of FAS victims in the juvenile and adult systems, those with substantial lifelong medical expenses, and those in need of other social services. Conservative estimates indicated each FAS baby would cost society an additional $1.5 to $2 million.

S.B. 197 was a significant step toward tackling those problems. It created an advisory subcommittee on FAS within the Health Division's Advisory Board on Maternal and Child Health. Members of the 11-member subcommittee were appointed by agencies, organizations, and institutions of higher education that were responsible for the care and delivery of services to persons affected by FAS. Members served 2 year terms without compensation, except travel and per diem, and they could be reappointed. Their powers and duties included:

• Assisting the Health Division in the development of a public education and awareness program with regard to fetal alcohol syndrome.

• Collecting and reporting pertinent information including statistical data.

• Assisting the University of Nevada Medical School in the development of continuing education curricula the university had volunteered to teach for free to the providers included in the bill.

• Assisting with the review and distribution of guidelines to assist healthcare providers in identifying women at risk and children who might have FAS.

Senator Wiener stated the measure provided confidentiality protections for any referral of a pregnant woman for prevention or treatment services. Moreover, S.B. 197 also required the Health Division to:

• Develop and carry out programs relating to the prevention and treatment of FAS, including programs for public awareness, the training of school personnel, and the use of a toll free information and referral service.

• Collect certain statistical information about children who were adopted, placed in foster homes, or placed in protective services.

• Develop a system to monitor FAS in Nevada, including the identification of at risk areas and the evaluation of perinatal delivery systems including potential deficiencies in those systems.

• The division could accept gifts, grants, or donations related to those activities and administer a special account established for that purpose.

Senator Wiener related an inspiration for S.B. 197 was her 86-year-old aunt who volunteered 30 hours each week to the neo-natal unit at University Medical Center in Las Vegas. She was the person who first told Senator Wiener about the tragedy of the "alcohol babies." The bill's provision regarding gifts was personally meaningful because with the passage of the bill and its signature into law, Senator Wiener would donate $1,000 to that account. It was a small way she could say "thank you" to her aunt for the thousands of hours she had donated to the care of the "alcohol babies."

She provided letters of support (Exhibit D) from Richard Steinberg, president of Westcare, Kirby Burgess, director, Department of Family and Youth Services, Clark County, and from Bernard Feldman, M.D., chairman, University of Nevada Department of Pediatrics.

In closing, Senator Wiener told the committee FAS was an American tragedy inflicting hardships on all who came within its sphere of influence. The greatest part of the tragedy was that it was 100 percent preventable; however, to prevent FAS from occurring mothers-to-be had to be educated about the dangers of drinking while pregnant. S.B. 197 was a tremendous tool to help accomplish the task. For those and other reasons she urged support of the bill.

Chairman Freeman noted in the bill's preamble Nevada was again number one in FAS statistics. Senator Wiener confirmed Nevada tended to be high in the chronic drinker, binge drinker, and teen pregnancy statistics. The drug of choice for teens was alcohol because it was legal and accessible.

John Yacenda, deputy director, Department of Human Resources, discussed how the bill had been organized. A subcommittee on fetal alcohol syndrome had been created from the Maternal and Child Health Advisory Board. It would allow the subcommittee to function in the context of a statutory body and contribute to the annual report produced by the advisory board, thereby helping to encourage and develop policy for the state as well as different programs of delivery. It was hoped that would provide an opportunity for those issues to be developed in such a way there would be an end to the development and not just a study group but a mechanism that would lead to policy development and effecting programs.

Dr. Yacenda provided written testimony (Exhibit E) that reiterated many of the statistics and highlights of the bill presented by Senator Wiener.

Next to speak, from the Las Vegas videoconference site, was Dr. Colleen Morris, geneticist and pediatrician, University of Nevada School of Medicine. She explained fetal alcohol syndrome was caused by prenatal exposure to alcohol. The alcohol readily crossed the placenta to circulate throughout the fetus causing growth retardation, particular facial features, and could cause birth defects. The most serious effect was on the developing brain. The effects on any particular infant depended upon several factors including the duration of the exposure, amount of exposure at one sitting, the health and nutritional status of the mother, and the genetic susceptibility of the fetus. Alcohol use was increasing among women nationally and among pregnant women, and there was evidence that FAS was an epidemic in Nevada.

Dr. Morris provided a graph (Exhibit F) detailing the incidences of new diagnosis of both FAS and Downs Syndrome in the Nevada Genetics Program. The program began in 1988 and showed the first 10 years of the clinic's operation. The rate of FAS had increased significantly in children referred to the genetics clinic at the University of Nevada School of Medicine and if statewide statistics were known would undoubtedly show a similar increase. Primary disabilities among FAS children included:

• Increased risk for mental retardation,
• attention deficit disorder; and
• microcephally.

Secondary disabilities were things that could be prevented with early diagnosis of FAS and professionals could intervene with those children to produce a better outcome. Children with FAS had a very difficult time and their adoptive or foster families might not understand their behavior problems were not willful but due to prenatal damage. In addition to human costs there was also a financial toll to the state, as illustrated on page 2 of Exhibit F, of $88,086 per year for just 14 children who had been referred to the genetics clinic during one week in October 1998.

In closing, Dr. Morris emphasized the importance of the state having a coordinated effort and to work more vigorously on the program to prevent FAS from occurring. But for those with FAS it was important to have early services to prevent secondary disabilities and to be able to identify the first case in a family soon enough to prevent having repeated cases in one family. There were several families who came through the clinic with more than one child with FAS, and the record in the state was a family of eight siblings, all with FAS, and all in foster care. For those and other reasons, Dr. Morris urged support of S.B.197.

Chairman Freeman asked how many years of a child's life was represented by the $88,000 cost. Dr. Morris replied it represented 1 year only.

Assemblyman Manendo asked how the Maternal and Child Health Advisory Board would be funded. Dr. Yacenda said the board was currently funded by Title V block grant which provided a budget for subcommittee activity.

Assemblywoman Leslie advised she was the assembly representative to the Maternal and Child Health Advisory Board and Senator Carlton was the other representative. She asked how the new subcommittee related to the existing committee on perinatal substance abuse. Dr. Yacenda responded there would be some overlap; however, the overriding sentiment in the senate and elsewhere was the FAS issue had been ignored for so long and the financial toll over an individual's lifetime so great that as much as possible should be done. Also, it was hoped the two subcommittees would merge in time as sophistication of knowledge and understanding was at a higher level based on policies and programs. Ms. Leslie followed up to clarify that the perinatal substance abuse committee would be examining drug related issues and the new subcommittee would focus on alcohol related issues. She next asked about section 10, subsection 2: what was the funding source for the evaluation described therein. Dr. Yacenda said it would be the Maternal and Child Health Advisory Board budget. Ms. Leslie asked if Senator Wiener anticipated foundation support to augment the funding. Senator Wiener said she did, additionally there were grants for which the board could apply. They intended to be creative in seeking out funding sources.

Finally, Ms. Leslie asked if the Department of Child and Family Services advised foster or adoptive parents in advance of placing FAS children. Dr. Yacenda confirmed that was being done and the bill language simply ensured that all public agencies would do the same.

May Shelton, director, Washoe County Social Services, stated her division was responsible for child protective services in the county. They supported S.B. 197

and looked forward to working with the Health Division in providing the required information.

From the Las Vegas videoconference site, Adrienne Cox, assistant director of Clark County Family and Youth Services, who was responsible for child protective services as well as the juvenile delinquency services, explained her department dealt with the effects of FAS in the child protective services and in the delinquency programs. Among other things, S.B. 197 would require that information be collected relating to the instances of FAS. Children affected required extensive services throughout their lives due to mental, developmental, and behavioral problems caused by in utero alcohol exposure. Despite expensive and lifelong interventions, some of those children did not survive and those that did never realized the life potential of an unexposed child. Ms. Cox said her department handled over 300 drug exposed infants a year and she suspected many more suffered from the effects of alcohol exposure but were not so identified at birth.

Ms. Cox urged passage of S.B. 197 because it would help educate the public about the dangers of drinking while pregnant, integrate services for prevention and treatment, collect statistics, and provide training to educational and medical personnel.

Lawrence Matheis, executive director, Nevada State Medical Association, voiced support for S.B. 197 and stated it was a good bill and an important issue.

Dave Kaul, counselor and integrated services case manager with the Family Drug Court, Second Judicial District, stated in his experience he saw many FAS children and adults who exhibited the same cluster of symptoms. Public education and training for community human service professionals was critical and he believed the subcommittee provided under S.B. 197 could move toward making that happen. He echoed the facts and sentiments of the earlier witnesses. Although he was sorry to see the money removed from the bill because he believed for every dollar spent, $3 to $5 hard money could be saved later on, it was nevertheless a move in the right direction.

Chairman Freeman announced Mr. Kaul had delivered to her a letter (Exhibit G) from Judge Charles McGee, Second Judicial District Court, Washoe County, expressing unequivocal support for S.B. 197.

Last to speak was Dr. Mary Guinan, state health officer, who expressed support for S.B. 197. A key aspect of the bill was that it provided for understanding the need for treatment services for pregnant women who were substance abusers. The need now was unknown, and there was a limited capacity for treatment of any substance abuse during pregnancy. Many programs would not take pregnant women or women with children, and often would not take Medicaid. The need had to be known so that treatment could be provided for the unfortunate syndrome.

Chairman Freeman expressed the hope that with Dr. Yacenda's capable help something could be done at the state level. She told Senator Wiener a vote would not be taken then, but it looked like a clean bill that would not need to be amended. She closed the hearing on S.B. 197 and opened the hearing on S.B. 398.

Myla Florence, administrator, Welfare Division, identified herself and provided her written testimony (Exhibit H). She explained S.B. 398 had been requested to comply with the federal requirement to disburse child support collections within 2 business days as mandated by the National Welfare Reform Law. The bill was developed in conjunction with the Controller's Office and the Budget Division. The state disbursement unit would be the central point for receipt of child support collections statewide providing both in state and out of state employers, noncustodial parents, and other entities one single location in which to submit child support payments. The intent of the fund was to allow the state disbursement unit to efficiently receive and disburse collections and the unit would be jointly operated with the Clark County District Attorney's Office. The Interim Finance Committee approved the configuration of the state disbursement unit in December 1998. In fiscal year 1998, the Welfare Division disbursed approximately $16 million in public assistance-related child support collections.

Ms. Florence then introduced Leland Sullivan, chief, Child Support Enforcement Unit, who had no testimony to present but offered to answer any questions.

Chairman Freeman reported the Committee on Government Affairs had heard a Senate bill earlier that day regarding fines that had gone to various state agencies and money not accounted for over the years. In that vein, she asked who would administer the fund and what were the accountability factors. Ms. Florence answered the agency fund would be administered by the Welfare Division just as it currently administered the public assistance collections and disbursements. Under federal law, all child support, income withholding payments from employers, and so forth must go to one single location in each state for distribution. Mrs. Freeman asked how often the agency was audited. Ms. Florence said it was done annually by an independent firm. The legislative staff conducted an audit every 8 or 9 years.

Assemblywoman Leslie commented in reading the bill it appeared there was not much of a choice and asked for confirmation. Ms. Florence said that was correct, it was a federal mandate.

Assemblywoman Angle questioned line 15 wording which stated "after deducting any applicable charges," and wondered if 100 percent of monies collected went to the child. Ms. Florence said all monies went to the child with the exception of money that might be owed to the state for public assistance payments. In other words, paying back the state for temporary assistance to needy families (TANF) that might have been paid on behalf of the child while child support had not been paid.

Chairman Freeman asked the potential for funds to exceed disbursements. Ms. Florence said anything above and beyond state and county administrative expenses as well as disbursements to children was returned to the general fund. Mrs. Freeman was not pleased to hear that and said she would much rather see it go into some kind of service in the division than returned to the general fund. She asked if the law required that it be returned to the general fund. Ms. Florence said it had been a determination by the legislature and the executive branch. Subsection 1 of section 2 stated "a continuing fund without reversion" but at subsection 3 of section 2 it stated the money in the fund must be used to carry out the provisions of the child support enforcement provision. Any money coming in needed to be used for the provision of the services provided by the child support enforcement program as well as disbursing payments to children. Mrs. Freeman was reassured to hear that.

There were no further questions. The Chair announced a vote would not be taken until all the members were present. She closed the hearing on S.B. 398 and opened the hearing on S.B. 519.

First to testify was Fred Hillerby representing the Nevada State Board of Pharmacy in support of S.B. 519. He introduced Keith MacDonald, executive secretary, Nevada State Board of Pharmacy.

Mr. MacDonald explained there were four sections of the bill which changed the ability of people to possess and administer drugs. Beginning on page 1, line 14, in the controlled substances act, Nevada Revised Statutes (NRS) 453, a euthanasia technician could possess and administer a controlled substance rather than a specific drug, sodium phenobarbital. The reason for change related to euthanasia for animals only from a single entity drug to mixtures of drugs. Similar mention had been made on line 29, page 3. Page 6, section 5, related to the veterinary statutes. The veterinary board was aware of the change and in agreement with it.

On page 3, in accordance with applicable regulation of the State Board of Pharmacy, an animal control officer, wildlife biologist, or employee designated by a federal, state, or local government agency whose duties included the control of domestic, wild, and predatory animals were included in the section of the controlled substance act to possess certain controlled substances. Experiences in Washoe County where mountain lions had come down into the school district had shown a need for wildlife biologist or animal control officer to drug the animal so it could be relocated.

In Chapter 454, the dangerous drugs act applied to nursing. In accordance with regulations allowed a nurse employed by a health care agency or health care facility authorized to provide emergency care or respond to the care of a patient in the home, to possess and carry certain drugs that might be used for a patient on an emergency basis. The list of drugs could be expanded at any time the Home Nurses Association desired to include other drugs for the benefit of patients in their homes. Part of the bill had been amended in the Senate committee that heard it to be under the authority of the medical director of such an organization who worked in the State of Nevada.

The final section would authorize pharmacists who could be trained and certified to carry out the standards and practices for immunization programs and authorized to administer immunizations to persons who were over 18 years of age. Immunization would include flu, hepatitis, and so on, as ordered by a physician in the State of Nevada.

Mr. MacDonald noted Nevada ranked in the lower 10 percentile in vaccinations and immunizations. Past observations revealed persons wandering in office buildings with styrofoam cases offering immunizations. No one knew where they were from. In other instances, card tables had been set up in markets for the same purpose, often by an out-of-state medical director. Therefore, in agreement with Lawrence Matheis, executive director, Nevada Medical Association, the language had been amended to suggest the person administering the vaccination or immunization did so only under the protocol and authorization of a Nevada doctor.

Mr. MacDonald provided an addendum to testimony of S.B. 519 (Exhibit I) presented when he earlier testified before the Senate committee. It contained a list of the 30 states that currently allowed pharmacists to give vaccinations. He indicated the most important part of the exhibit were the draft regulations that detailed the necessity for training certification and abilities of pharmacists to perform that vaccination. He added that in most chain store pharmacies there was not a place suitable for those vaccinations to be administered and that had been taken into consideration by the Board of Pharmacy. Only pharmacies that wanted to do it and advertised the service would be authorized.

Mr. MacDonald informed he had checked with Dr. Krolick, the Clark County Health Officer, the state epidemiologist, and Dr. Ted Randall in the state health office and all concurred it would be a good thing for public health policy.

Vice Chairman Koivisto asked if licensed pharmacists or pharm D's would be administering the vaccinations. Mr. MacDonald said they would be registered pharmacists if they were certified and qualified. Only about one-third of pharmacists had a pharm D degree. By the year 2002 all pharmacists would graduate from a pharm D program in the United States. He explained a pharm D was a post-graduate degree. Many pharmacists had a 6 year degree equivalent to a masters degree which they called a "pharm D" degree.

Chairman Freeman questioned the liability issue. Mr. MacDonald said pharmacists already had a liability insurance policy over and above the policy held by the firms who employed them. They would have to increase their liability for the purpose.

Assemblywoman Leslie asked if the lower 10 percentile ranking was for children and adults. Mr. MacDonald said both children and adults. Ms. Leslie asked if shots for travelers going overseas would also be available. Mr. MacDonald said if the doctor who offered the protocol with the pharmacist made the arrangement. She asked if he anticipated health management organizations (HMOs) would make arrangements with certain pharmacies for certain services. He said he had not thought that far ahead but would not be surprised if that happened. Ms. Leslie said she was not opposed if the cost to the consumer was lower and safeguards were in place.

Chairman Freeman asked about the specific area where the shots would be given. Mr. MacDonald prefaced his response by saying the reason shots would be given to adults only was because it was not deemed appropriate for a child to be given a shot in an unenclosed nonprivate area. Adults could do "drive-bys" and stick their arm out a car window and get a shot. He did not know if a specific place would be required, in fact the state board had not contemplated making a special room. Mrs. Freeman asked where the immunization clinics had been given. Mr. MacDonald said principally in Clark County, by an Arizona doctor. Mrs. Freeman said she would like to hear from Mr. Matheis.

Lawrence Matheis, executive director, Nevada State Medical Association, said they had concerns about the bill, but Mr. MacDonald and the State Board of Pharmacy allowed for amendments that had accommodated many of those concerns. Their major concern had been that immunization was a medical practice, it had significant medical implications, and a physician had to be accountable. He anticipated working on that issue with the Board of Medical Examiners to make certain if a physician established a protocol out of the direct sight and delegated authority of the physician, it was clear what procedures and protections would be in place and the medical record was appropriately noted.

Mr. Matheis said the association was not opposed to the bill; however, expressed a general concern about expanding the scope of various practitioners into areas where it was unknown where it would lead. There was potential risk. All of the licensing and regulatory agencies would need to gear up in order to ensure it did not get out of control, and they would need to take the oversight very seriously. The idea was an experiment that raised concerns, but with the protections built in, it could be tested to determine whether it worked and whether it needed further adjustment.

Chairman Freeman asked if there had been any adverse reactions resulting from the Arizona doctor's immunization clinic. Mr. Matheis said the problem was how to track that situation. If there were adverse reactions they would likely occur in the middle of the night and require emergency treatment, meanwhile the out-of-state doctor would be long gone. For that reason, under the proposed legislation, it was necessary to have a Nevada physician somewhere in the process. Mrs. Freeman asked if the person coming in for immunization would have a doctor's prescription. Mr. Matheis said that would be one method. However, equally important would be for a physician to have a relationship with a pharmacist and would work out a protocol to allow a patient who came in and asked for a flu shot to receive it under that protocol and with the protections built in.

Mrs. Freeman also had concerns. She asked when it might go into effect. Mr. MacDonald said a date had not been set but would come after the collaboration with the State Board of Medical Examiners and the State Medical Association. He added he was not sure it would be a gigantic process that suddenly unfolded in the state, it would be only specific pharmacists who desired to do it and were trained to do it which would require some time.

Assemblywoman McClain asked a question about senior citizens who might feel they needed a certain immunization that perhaps their doctor did not feel they needed or would not be good for them, could they get it anyway. Mr. MacDonald said he was hesitant to answer because if a person was dishonest they could probably bypass the doctor. There was probably no way to prevent that. Many people got controlled substances by going to multiple doctors until one prescribed what they wanted. As far as the proposed legislation, Mr. MacDonald said the situation would continue to be refined to ensure proper recording of information and so on.

Mrs. Freeman, still concerned, asked if there was a better way the end result might be achieved. Mr. MacDonald felt pharmacies would be ideal because they were not transient, they were responsible, had liability insurance, and would have relationships with doctors.

Mr. Matheis remarked it had been traditional, particularly with seniors, to have clinics set up at senior centers and those had been very successful. The target group was the working age adult because the childhood immunizations had lapsed and there had been periodic outbreaks of measles and other things. He expressed skepticism whether it would be a successful mechanism for dealing with that.

Assemblywoman Berman asked if there had been a breakdown in what the Health Department system was already doing for Nevada communities. Mr. MacDonald said in the senior programs Mr. Matheis had mentioned, some had been sponsored by pharmacists and they hired nurses to give the immunizations.

Vice Chairman Koivisto asked about pharmacists who worked in hospitals. Mr. MacDonald said any pharmacist could become qualified, and whether the hospital wanted to offer the service would be determined by their policy.

Mr. Hillerby stated it was clear, with what was already in place, people were still going without immunizations. He felt the board should be complimented for finding a way to address more of the adult population. Adults seemed able to remember to take their children for immunization but neglected themselves. He echoed Mr. MacDonald's belief it would not be an "exploding thing" where every pharmacy would be doing it. However, independent pharmacists were looking for a way to distinguish themselves from the big chains and this would also be a tool for offering a personal service to their community. He concurred with Mr. Matheis that all the safeguards should be in place, and with that done it was another opportunity to get more people immunized. That would be an accomplishment for the state.

Chairman Freeman asked if immunization was ever part of a safety program. Mr. MacDonald did not know. Mrs. Freeman said she did not distrust pharmacists at all, it just seemed to her the place itself was inappropriate and she would have to know more before she could support the bill. A discussion ensued. Mr. Hillerby was surprised by the concern about pharmacists performing the service when that was who one went to for other drugs to treat illness and injury.

Ms. McClain said if one was already at the doctor's office why did not the doctor give the shot instead of writing out a prescription for a pharmacist to give it. She also asked about the new language in section 4 of the bill, was that simply an expansion to include a patient's residence. Mr. MacDonald said currently a nurse could not possess a drug outside of the practice she was in or carry it on her person. The bill language expanded her ability to have the drug outside the practice or in their possession, principally for home care service. The Home Care Nursing Association had requested the language.

Assemblywoman Angle was concerned about insurance and supervision. If her physician gave her a prescription for a pharmacist to fill, it was her physician who would ultimately be responsible. She wondered if in the event of an adverse reaction to an immunization administered by a pharmacist would an HMO or preferred provider organization (PPO) cover hospitalization and/or treatment. She did not want to pass legislation that might remove accountability. She felt similarly about nurses having the ability to prescribe or inject; were they ultimately responsible or was the physician. Mr. MacDonald said it was his understanding the pharmacist would carry liability insurance to cover that situation. Also, the pharmaceutical companies who manufactured the product had a certain amount of liability. Additionally there was an federal program to protect children that sponsored care as a result of adverse reactions. Whether the HMO or PPO would be responsible would depend upon whether they had contracted to have that done. He added that pharmacists were being paid by organizations for services similar to those so if such an organization was paying, Mr. Macdonald assumed they would be liable along with the insured pharmacist.

Mr. Matheis said in regard to the home health nurses, the home health agency's medical director would specifically be held accountable. The drugs the nurse carried would have to be specifically listed in the protocol and the circumstances under which she could, on her own initiative, administer it.

Regarding the immunizations, he believed it would not be someone coming from a physician with a prescription for a shot to be given by a pharmacist, because the physician, on determining an immunization was needed, would give it himself. Instead, he believed the pharmacist immunization would be a drop-in situation and thus a cause for concern as to whom would be accountable. It would have to be the licensed physician who had established the protocol with the pharmacist. That would probably be the target of any liability challenge.

Chairman Freeman said a vote would not be taken at the time and S.B. 519 would be the subject of an upcoming work session.

With no further business before the committee, the Chair adjourned the meeting

at 3:40 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: