The Committee on Health and Human Services was called to order at 1:55 p.m., on Monday, May 10, 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. 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. Barbara Buckley

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Freeman announced the meeting would be a work session, according to the agenda. Thereafter, a presentation would be made by state officials regarding public health issues in anticipation of the tobacco proceeds, a portion of which would go to public health. Mrs. Freeman believed it would be helpful to committee members to hear what was going on in the state and what the committee should be considering in terms of long-range funding.

The Chairman then opened the work session on S.B. 10, the first item on the work session document (Exhibit C) prepared by Marla Williams.

Mrs. Freeman noted money would be coming to the state from the Robert Wood Foundation. She then asked if Dr. Yacenda was present.

Marla Williams, committee policy analyst, advised Dr. Yacenda, who was to have testified in regard to the bill, was out of town, therefore would not be present.

Mrs. Freeman explained she and Mrs. Buckley had been on the committee who had made the recommendation, and Dr. Yacenda had been very involved in the discussion and in getting the bill drafted. In view of the money expected from the Robert Wood Foundation, she wondered if there was still a need for S.B. 10. Since there was no one present to speak to the matter, no action would be taken at the time.

Chairman Freeman then opened the work session on S.B. 73.

Marla Williams noted the bill had been requested by Senator Raggio; however, Senator Rawson had testified on behalf of the measure at the April 28, 1999 hearing. He stated at that time the way the law was administered had to do with a business relationship, and a person could not conduct an evaluation if they had such relationship. In a private hospital, however, anyone on staff had a business relationship and therefore the measure clarified the business relationship was intended to mean a financial interest in a facility, such as a stockholder.

Assemblyman Manendo asked if there was a fiscal note on the bill. Ms. Williams said there was none shown on the reprint.

Chairman Freeman asked for a motion.

ASSEMBLYWOMAN LESLIE MOVED TO DO PASS S.B. 73.

VICE CHAIRMAN KOIVISTO SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the work session on S.B. 117.

Marla Williams noted the bill was heard on April 26, 1999. An amendment had been proposed, however, questions were raised and it was her understanding the committee was not ready to proceed on the measure.

Mrs. Freeman stated no action would be taken at the time until the questions on the amendment had been resolved.

Assemblywoman Berman asked why the bill was being held. Assemblywoman Leslie explained the bill was one on which she and Mr. Williams had questions and they were still reviewing the amendment. She was not sure the amendment in the work session document (Exhibit C) was satisfactory. Ms. Berman questioned the delay, and Ms. Leslie assured her it would be resolved shortly.

Chairman Freeman then opened the work session on S.B. 163.

Ms. Williams advised the bill had been requested by members of the Legislative Committee on Health Care. The hearing was held on May 5, 1999. Attachment E of Exhibit C contained two letters submitted in response to testimony received during the hearing concerning a proposed amendment in the Senate Committee on Human Resources and Facilities. One letter was from Senator Rawson, who chaired that committee, indicating they had received the amendment but chose not to act favorably on it. The second letter, a memorandum from Yvonne Sylva, administrator of the Health Division, stated currently there were no statutes or regulations governing the number of medical facilities or dependent care facilities that a person might own. Ms. Williams stated that had been the amendment discussed in testimony. She then referred to the letter from the Attorney General's Office (Exhibit D), a copy of which committee members had received, regarding the bill. Although Ms. Brushfield indicated she would submit an amendment, it had not been received by her or by the chairman.

Chairman Freeman noted the proposed amendment dealt with limiting the number of homes any one individual could own, however, in discussing it with others she learned that might be in conflict with federal law relating to restraint of trade. Under the circumstances, Mrs. Freeman felt the bill was ready to pass as written.

VICE CHAIRMAN KOIVISTO MOVED TO DO PASS S.B. 163.

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

` THE MOTION CARRIED UNANIMOUSLY.

The next bill for discussion was S.B. 519.

Marla Williams noted the State Board of Pharmacy had requested the bill, and it was heard on April 26, 1999. Additional testimony was received on May 3, 1999. Attachment F in Exhibit C discussed the bill.

Fred Hillerby, on behalf of the State Board of Pharmacy, provided additional information under attachment F from Robert Beach, state director, Nevada Animal Damage Control, to Keith McDonald, Nevada Board of Pharmacy. Mr. Beach's letter identified the situation in Nevada and why he had requested the bill. Further, it related to section 2 of the bill regarding the control of domestic, wild, and predatory animals, and the possession of a controlled substance for use by an animal control officer, wildlife biologist, or an employee designated by a federal, state, or local government agency.

Ms. WiIliams went on to say Mr. Hillerby offered to delete section 1, section 3, and section 5, because it appeared sodium phenobarbitol, the term replaced by "controlled substance" in the bill was an ingredient in each of the substances that was proposed for use. In section 2, the language stated they were attempting to authorize possession and administration of a controlled substance by an animal control officer, wildlife biologist, or an employee designated by a federal, state, or local government agency whose duties included the control of domestic, wild, and predatory animals. Removing sections 1, 3, and 5 would not affect that section. The euthanasia technologists came under a different licensing authority. The relationship would continue the same as it was. The new language would bring in the wildlife biologist and persons authorized by the state or federal agency and who had gone through a certification process.

Ms. Williams noted Mr. Beach had provided information (Exhibit E) pertinent to that portion of the bill, which concerned coyote attacks in the northern Nevada area.

Also submitted by Mr. Hillerby was a proposed regulation, on page 23 of Exhibit C, that concerned home health nurses, and would be enacted if the bill was adopted. The regulation listed those substances a nurse would be allowed to carry and specified the circumstances in which a nurse could carry those controlled substances.

Vice Chairman Koivisto asked if the section of the bill relating to pharmacists was being retained. Ms. Williams said subsection 17 of section 4 relating to pharmacists was being deleted.

Assemblyman Manendo asked when the proposed deletions of sections 1, 3, and 5 were given to Ms. Williams. Ms. Williams said Mr. Hillerby had given them to her earlier when they discussed amending the bill. Chairman Freeman said she was aware of that.

Fred Hillerby, representing the Nevada State Board of Pharmacy, stated he had learned on May 6, 1999, when he talked to the Board of Veterinary Examiners, who had asked the State Board of Pharmacy to change the sodium phenobarbitol to controlled substances. Upon further investigation they found the base drug of the new drugs on the market under a brand name was still sodium phenobarbitol, therefore, the change had not been needed.

There was no further discussion and Chairman Freeman asked for a motion.

ASSEMBLYWOMAN VON TOBEL MOVED TO AMEND AND DO PASS

S.B. 519.

ASSEMBLYWOMAN BERMAN SECONDED THE MOTION.

THE MOTION CARRIED.

The last measure on the work session was S.C.R. 11.

Ms. Williams advised the measure had been introduced by Senator O'Connell. A hearing was held on April 28, 1999, and a subcommittee, co-chaired by Assemblywoman Leslie and Assemblyman Manendo, held a hearing on May 7, 1999.

Ms. Leslie advised the subcommittee heard testimony from two individuals from the Crisis Call Center, in Reno. Ms. Williams also contacted the program in Las Vegas. After considerable discussion a decision was made to present an amendment to the committee for its consideration. Essentially, the amendment changed the "resolved" sections in the resolution to "whereas" clauses. It asked for $100,000 for each year of the biennium to be allocated to the Division of Mental Health and Developmental Services who would in turn fund community-based contracts for statewide suicide prevention services. It would provide a base funding for a suicide prevention hotline in the state. That potential amendment was contained at attachment G, page 24, of Exhibit C.

Ms. Leslie added that she and Mr. Manendo were disturbed to learn about the lack of services in the Las Vegas area.

Mr. Manendo commended the individuals at the Crisis Call Center in Reno for the great job they were doing. He expressed the hope that southern Nevada had an opportunity to see what that center was accomplishing. He emphasized the importance of the committee taking a stand on the issue. It was vitally urgent because Nevada ranked first in suicide statistics. When the resolution came before the committee it was basically a "feel good" measure urging the legislature to do something for the people of Nevada, which it already had the ability to do. By appropriating some money it enabled the measure to make a difference. Mr. Manendo commended the committee and Chairman Freeman for her leadership in allowing a closer examination of the issue.

Mrs. Freeman noted the measure would have to go to the Committee on Ways and Means, if the members acted on it. She then asked for a motion.

ASSEMBLYMAN MANENDO MOVED TO AMEND AND REREFER

S.C.R. 11 TO THE COMMITTEE ON WAYS AND MEANS.

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

The Chair invited discussion.

Assemblywoman Gibbons expressed strong support for the measure, for the funds appropriated, and hoped it would be approved by the Committee on Ways and Means. She related she had lost her father to suicide when she was 16 years old, and he was only 40, she knew well how it could stigmatize family members for many years. She hoped more would be learned about the tragedy of suicide, such as the depression that led up to it, and also possible chemical differences in the brain of those who committed suicide.

Assemblywoman Von Tobel asked if it was necessary to note from which fund the $100,000 appropriation would come, because it was not indicated, and she felt it should be the general fund. Ms. Williams agreed, that should be indicated and would be included in the amendment.

Assemblywoman Angle asked if the maker of the bill was in agreement with the amendment, and second, because of the appropriation, might the bill be jeopardized. She expressed concern for the issue and wanted to make sure the amendment would not kill the bill. Ms. Leslie responded Senator O'Connell had been informed; however, she had not received a response from the senator. To the second question, Ms. Leslie said because it was being changed from a resolution to a bill, in effect, the resolution was being killed.

Mrs. Freeman said the committee was asking the concept to be considered. However, if they were uncomfortable with that action it would not be rereferred and instead taken to the floor for a vote.

Assemblyman Manendo felt the bill needed to go to the Committee on Ways and Means. Putting the appropriation in underscored its importance. Moreover, he noted that the American Foundation for Suicide Prevention would be presenting the 1999 Public Service Award to Senator Reid for his efforts in passing Senate Resolution 84, in 1997. That resolution made suicide prevention a national priority, and now, 2 years later, Nevada was saying that was very important. "We need to do something, and this committee is doing that." Mr. Manendo commended Senator O'Connell for bringing the resolution forward, but the committee had put some "teeth in it. We're making a policy statement here in the State of Nevada."

Mrs. Freeman agreed that it was appropriate, and could not imagine it would be killed simply because an appropriation was requested. She then took the vote.

THE MOTION CARRIED UNANIMOUSLY.

The Chair then closed the work session. She noted there would not be a meeting on Wednesday, May 12, 1999, as the Committee on Commerce and Labor had asked to use the time. Unless an emergency meeting was called, anything further for the Committee on Health and Human Services would be done on the floor. Mrs. Freeman commented the 120 day session had changed the way the legislature conducted business, but everyone was trying to make the best of it.

Chairman Freeman then asked Ms. Leslie to address the committee regarding questions she had about the Indian Commission.

Ms. Leslie noted the Reno-Sparks Indian Colony was in her district and she wanted the committee to know she was continuing to work on the issue. She felt it was not something the committee could address on the last meeting of the session; however, she would be following up with the governor to address some of the problems raised by the people who testified at last week's meeting. She acknowledged there were serious problems with the Indian Commission, which had not been fulfilling its statutory obligations, and she would continue looking into it as would Assemblyman Williams.

Returning briefly to S.B. 10, Mrs. Freeman stated she wanted to work with staff on the matter and might call for a special hearing to discuss some of the things that could not be done at the meeting.

Assemblyman Williams asked to comment on S.B. 117. He had been working with Ms. Leslie on the matter and they had drafted an amendment; however, there were still some concerns to be considered but those should be resolved shortly.

Mrs. Freeman then introduced Dr. Robert Miles, with whom she worked when she was on the board at Washoe Medical Center. Dr. Miles was the chair of the Board of Trustees of Washoe Medical Center at that time.

Mrs. Freeman next introduced Dr. Mary Guinan, state health officer, Wendy Pappas, from Washoe County, Jim Begbie , health services officer from Washoe County, and David Rowles, the director of administrative services, from Clark County, all of whom would make a presentation on public health issues.

Dr. Mary Guinan said she had been very interested in the committee's discussion on the issue of suicide, because it was important to her also. The state's lack of investment in prevention perhaps had resulted in the high suicide rates.

Chairman Freeman had asked her to address several matters. One was to explain how the State Health Division budget had been cut since 1990 and what programs that had impacted.

In 1992 and 1993, because of a shortage in general funds, the appropriations to the State Health Division were cut by $5.2 million. It had never been restored. The brunt of the impact of that reduction was felt in two areas: (1) Special children's clinics in Las Vegas and Reno. Services were reduced and resulted in a waiting list. Other resources were used to try to relieve the waiting list, but it had never been completely resolved. There was still a waiting list. (2) Health aid to counties. The allocation to Washoe and Clark counties for health promotion and disease prevention was reduced by 50 percent in 1992 and 1993. The amount of $1.3 million had never been restored.

Dr. Guinan referred to the first of several charts (page 1, Exhibit F), titled Health Division Funding, which illustrated fiscal year 1998 and projections for fiscal year 2000. For 1998, federal funding represented 47 percent of the budget, which was for prevention and health promotion, the core of public health. The investment by the state from the general fund was 17 percent of the budget; other sources accounted for the remainder. In the year 2000, the state funding would drop to 15 percent while the federal funding would increase to 50 percent. On a national basis, the federal funding streams were decreasing and could not be depended upon. They also had strings attached and were linked to federal priorities. State priorities could not be implemented because there was of a state investment in prevention and health promotion.

Following 1996, information was gathered from conversations with the citizens of Nevada from all communities information was gathered concerning the needs for promotion and prevention. The result was a publication entitled "Nevada State Health Division, An Overview of Programs" (pages 8 to 23 of Exhibit F). That document contained the state's priorities; however, the funds were never available to implement the plan. Attempts were made to do some effective prevention in health promotion in two areas, and they were very effective. One was immunization of children, and results found dramatic reduction in such illnesses or diseases as hepatitis B, measles, and H-influenza B, and Meningitis, had practically been eliminated in Nevada. Those results had occurred as a result of federal, private, and state funds. The state funding for immunization had been limited to buying vaccines. All the rest of the money invested in the program had come from private sources through a great deal of work by a lot of people and through use of federal priority monies that were in line with Nevada's priorities. Page 3 of Exhibit F, "Immunization Status of Nevada Two-Year Olds 1991-1998" indicated an increase from 34.7 percent to 73 percent, and would prevent many devastating diseases in those immunized. When resources were available there were effective ways of preventing disease and promoting health.

Another serious issue was teen pregnancy. Nevada had one of the highest rates in the nation. As a result of federal and private funding, a statewide prevention program was undertaken that resulted in a decrease in teen pregnancy rates among 15 to 17 year olds from 70 per 100,000 to 50 per 100,000. Dr. Guinan said "When behaviors had to be changed, the community had to be involved. If the community did not buy in, then it's not going to be effective."

Dr. Guinan further reported there was no infrastructure in the rural areas to take into account the health promotion and disease prevention programs. She added there were very effective programs that could be introduced and good people who could implement them, an entire network who could make a difference. However, without resources nothing could be done. Teen pregnancies had historically poor outcomes for children and for parents, and it was in the interest of the health of the state to reduce the numbers.

Chairman Freeman recalled when the former attorney general initiated community involvement some years earlier. At the time it was a new concept, and it was gratifying to hear that it worked, and perhaps it could be effective with teen smoking.

Dr. Guinan continued, stating the health issue with which the Health Division had not been successful was lung cancer, because there had be no interest in investment in prevention. Mortality rates from 1991 to 1997 in Nevada had increased dramatically, in contrast with the national trend that had decreased. Lung cancer was directly related to smoking. Nevada had the fourth highest rate in the nation of 28 percent, plus a 30 percent smoking rate for women. Lung cancer mortality in Nevada killed more women every year than breast cancer and cervical cancer combined. There were no prevention programs for women in the state that the state implemented, it was either voluntary groups or others who did that. California, which previously had one of the highest smoking rates in the nation, implemented a well-funded tobacco prevention program and resulted in their having the second lowest rate in the nation. Utah had the lowest rate in the nation.

Mrs. Freeman asked Dr. Guinan if she had been approached by the money committees to present her findings when they considered how to use the tobacco settlement money for public health. Dr. Guinan said she had not. Mrs. Freeman then asked if, when she did go before those committees, she had outlines of exactly what she wanted to do with those proceeds and what the budget would be. Dr. Guinan said the state had a plan and knew what the priorities were but needed to go through a process of understanding where the most effective preventions were, how to get the most for the money, and they had to bring the community into that. It could not be done from the top down.

Dr. Guinan stated the health departments in Washoe and Clark counties did wonderful work; however, there were 15 counties without health departments. There was a network of community nurses who did health care, but there was no infrastructure to implement any of the prevention programs which were needed. Community groups needed to be organized to help make decisions on what had to be done. Therefore, there had to be either regional health departments who would service a number of counties, or the individual counties needed a health department. There had to be a funding source, and if the tobacco settlement money could help build an infrastructure, especially in the 15 counties, it would make an impact on 21 percent of the population who lived in rural Nevada.

Mrs. Freeman asked how, if the money became available, it would be structured. Dr. Guinan envisioned that a trust fund would be established and the counties could decide what they wanted and then apply for the money from the trust fund. It would be administered by an advisory committee or the State Health Division. The State Health Division would then connect with those counties and work with them on a regular basis. It would be a process of getting the local people involved in what they wanted and not the state telling the people what the state wanted.

Mrs. Freeman asked if the Governor's Office had any plans for the next session in regard to bill drafts on the issue. Dr. Guinan did not know.

Dr. Guinan next discussed the issue of suicide, reiterating Nevada had the highest rate in the nation but no investment in prevention. Funding was needed to do research on the factors related to suicide. The state was losing its young people to suicide and did not know why. The rate would continue to be high until the state understood what was needed to stop the suicide epidemic in Nevada.

Finally, Dr. Guinan explained the chart on page 7 of Exhibit F was done by ReliaStar, a national group who ranked the health status of all states. Nevada was 47^th. The goal was to make Nevada number one. The legislature needed to help by understanding the need for investment in prevention. Public health was not health care for the poor, it was prevention and health promotion. "We had to understand what is unique in our state and the unique interventions we need in our state. To do that we need to do research." She added an investment in prevention was cost-saving for everyone. She pointed to the issue of senior health and a recent study that showed if senior citizens were kept physically active they avoided disability and admission to nursing homes by 9 years. A health promotion program for seniors throughout the state that included immunizations and physical activities appropriate for seniors would prevent them from becoming disabled and going into nursing homes, which was so costly. But most important, it would improve the quality of life. Dr. Guinan noted Nevada was 50^th, the lowest state in health spending, and the statistics bore that out.

In conclusion, Dr. Guinan said there was a critical need for an independent funding source that would be continued on an ongoing basis, and the results could be seen in a very few years.

Assemblywoman Angle asked about teen pregnancy statistics and wondered if the decline was in pregnancies or in births. Dr. Guinan said it was in pregnancies which she believed was directly related to the "Abstinence Only" program going on in the schools.

Ms. Angle then asked about Utah being the lowest in smoking statistics, and whether that was a result of a state program or was lifestyle and value based.

Dr. Guinan felt, having lived in Utah a number of years, it was value system that discouraged smoking. However, she cited the decline in California that was the result of a state awareness and prevention program, so both values and a health awareness-smoking prevention program were needed. California understood that and studied the relationships, and chose health promotion and prevention programs believed to be most effective for its communities.

Mrs. Freeman suggested to Ms. Leslie and Mr. Manendo when speaking to Senator O'Connell about her bill on suicide discussed earlier, to mention Dr. Guinan's report and perhaps elicit her support.

Mrs. Freeman then asked Dr. Guinan about the anticipated research, would it involve the universities and various databases around the state. Dr. Guinan said she saw it as a grant program with strong university involvement. Scientists were needed to do research, behavioral scientists especially. The Health Division would work in cooperation with them, but the research would be independently conducted, the results would be shared, and it would take a great deal of work to understand the suicide problem and the related factors.

The next presentation was made by several individuals. David Rowles, director of administrative services for the Clark County Health District, introduced himself and his assistant, Carl Munniger, administrative manager. Jim Begbie, acting district health officer, Washoe Health District, introduced himself, and Dr. Bob Miles, the chairman of the District Board of Health, and Wendy Pappas, assistant director of community and clinical health services.

David Rowles spoke first regarding the funding of public health in the two largest counties in Nevada. In Clark County there was approximately two-thirds or 66 per cent of the state's population, consequently it had the largest number of incidences related in Dr. Guinan's statistics on suicide, teen pregnancy, and so on. Prevention was a large part of what they did, however, at times it had been a lesser priority in the legislature and until now had not received the focus it deserved. Public health professionals found it extremely frustrating to meet session after session to plead their cases and have other priorities get in the way. Mr. Rowles commended the committee for its interest and thanked the Chair for the opportunity of addressing them.

Mr. Rowles provided a packet of information (Exhibit G) containing a letter from Donald Kwalick, M.D., the chief health officer of Clark County, to the Senate Finance and Assembly Ways and Means Committees. In the letter, Dr. Kwalick cited the lack of concern and focus on restoring the aid-to-counties budget that had been voluntarily reduced by the Health Division to assist the state's budget problems in 1991.

Mr. Rowles provided background on the Clark County Health District that was organized 37 years ago and represented all of the incorporated jurisdictions and the unincorporated county. It had membership from Clark County, Las Vegas, Henderson, North Las Vegas, Boulder City, and Mesquite. The Clark County Health District was staffed by 420 full-time equivalents, plus periodic and full- time independent contractors in the medical fields. There were four divisions within the district: air pollution control, environmental health, nursing and clinics, and administrative services. The office of epidemiology was recently added.

He echoed Dr. Guinan's comments regarding the need for scientists to do studies on the causes of health problems. In that regard, the district had a Ph.D. epidemiologist and four staff epidemiology researchers who were studying the incidences of disease which would also include suicide. The district was a vital statistics registrar that collected all birth and death certificates and used their database and computer technology to elicit meaningful insights. Additionally, the district performed many functions for the state and as a result saved the state money that would otherwise be spent on staff and services in Clark County. Moreover, Clark County sales tax dollars were used to implement programs and to supplement those which were partially funded by the state.

Mr. Rowles cited the Clark County Health District mission statement, on page 5 of Exhibit G, which was "to protect and promote the health, the environment and the well-being of Clark County residents and visitors." He said he often felt the district health departments were taken for granted, simply because they had an invisible public image. Nevertheless, it played a vital role in maintaining air quality, water quality, food purity, waste management, disease control and prevention, as well as emergency medical services.

Clark County Health District core public health services included:

• Preventing communicable diseases;
• Monitoring and reporting on local health conditions;
• Developing policies and implementing programs which promoted health and quality of life;
• Promoting health through local outreach education;
• Empowering self improvement in personal health;
• Protecting local environment, workplace, tourists accommodations; and
• Planning for and responding to local mass casualty events and incidents.

The original per capita rate in the early 1980's was $1.10. That changed in 1991 when a severe cash flow and financial crisis occurred at the state level. Clark County at that time was quite stable. Representatives from the State Health Division asked Clark County to voluntarily surrender its legislatively-approved $1.10 per capita by 50 percent, in order that the state would not have to implement furloughs and layoffs in various divisions. Mr. Rowles said Clark County agreed to do that in the spirit of cooperation, because a good relationship between the county and the state was enjoyed then and still was. However, the county had not been successful in achieving a return to the prior per capita funding level. Washoe County had also agreed to surrender 50 percent of its legislatively-approved per capita funding.

Mr. Rowles referred to the chart on page 8, Exhibit G, which illustrated the increase in population in Clark County versus the per capita spending. He stated it was increasingly difficult to provide services to the county's growing population with only 55 cents per capita. The total loss of revenue from that voluntary reduction was nearly $5.5 million. Without adequate funding, efforts were limited. Both Clark and Washoe Counties worked tirelessly to meet the needs of a population that had serious health issues that were not being addressed. Another important service provided at the county level was maternal and child health services, which included: Adult and child immunizations; 273,000 given last year. Of those, 30,000 were flu shots, 5,000 hepatitis-A, and 5,000 infant hepatitis-B and chicken pox. The district was trying to promote a broader use of hepatitis-A in the food handler programs to replace tuberculosis skin testing. In 1998 they processed 128,000 health cards; 60 percent were renewals and 40 percent were new health applicants. If each one had a hepatitis-A shot the health outcomes of the communities would be greatly impacted. The district needed to find a way for the local communities, hotels, motels, and restaurants who hired food handlers to help offset the cost. An increase in the aid-to-counties would be part of the consideration that could be used to offset some of the costs and improve the health of local communities.

Assemblyman Manendo suggested Mr. Rowles request a resolution from the county commissioners in support of the plan to have hotels and restaurants help offset the cost of the hepatitis-A immunizations. Mr. Rowles responded two members of the county commission were on the Clark County District Board of Health and they were supportive of the program. He said two other important groups from whom to gain support were the Nevada Resort Association and the Culinary Union. Mr. Manendo asked if those two members on the board had gone forward with a request for resolution. Mr. Rowles said they had not, because the Clark County Health District was an independently organized and managed entity. It was not under the direction of the county commission. He added the initiative also had the support of the city councils of Las Vegas, North Las Vegas, Boulder City, Henderson, and Mesquite. Mr. Manendo asked if those councils had forwarded information to the Resort Association. Mr. Rowles said it had been forwarded by the Clark County Health District.

Chairman Freeman suggested that Mr. Rowles tell everyone he knew and ask them to lobby members of the legislature. Mr. Rowles said it would take more planning to implement the program but hoped it would accomplished by July 1999.

Mr. Rowles continued to outline the maternal and child health services:

• Well-baby checks; 2,500 done last year.
• WIC Services (Women, Infants & Children Supplemental Food Program).
• Family planning; 10,000 patients last year.
• Baby Find; 500 clients served by volunteer mothers, pre and post-natal care.
• Public health nursing; more than 5,000 home visits to low income families.

Assemblywoman Von Tobel asked if the statistics included tourists. Mr. Rowles said "Yes." It involved district sources when, for example, in an outbreak of salmonella, the epidemiological team went out to interview people to find out what they ate, where they ate, and so on. But, he pointed out, many of the residents ate next to the tourists so they were at risk, as well.

Mr. Rowles also noted any given day the city of Las Vegas had 200,000 additional people in the city that did not live there but still required care. Much of which came back to the Clark County Health District as a responsibility, and that was not figured in the per capita rate.

Mr. Rowles then provided a chart (page 20, Exhibit G) of 21 positions cut from

the current year's budget.

Ms. Von Tobel asked if those positions were enhancements to the staff. Mr. Rowles said they would be additional positions.

Mr. Manendo said that struck a debate about what was the responsibility of all the government agencies, including the legislature, for all the tourists coming in and how was the state expected to pay for services provided to them. That had been an ongoing situation, and it needed to be taken seriously. "Someone needed to step up to the plate and come up with money for those services." He said he was often asked by constituents why they were expected to pay for tourist services. Mr. Rowles noted they did charge for permits and so on, but the entrepreneur felt he was being charged too much.

The last program Mr. Rowles discussed was the poison control center, which until last year was supported by the Columbia Sunrise Hospital. However, when the hospital said it would no longer support it the Clark County Health District took over that program at a cost of $10,000 per month, because they felt it was a priority. There had been no offset from the community at large or from the private medical community for contributions. There were more than 15,000 calls to the center since ownership was taken over by the district. Over 3,000 calls required immediate medical intervention.

Finally, Mr. Rowles cited the goals for the health district. They subscribed to American Public Health Association's Year 2000 goals and objectives. Others were:

• To find and maintain funding for local poison control hotline;

• To plan for bio-terrorism and readiness in tandem with the bill recently passed by the legislature;

• To expand hepatitis-A immunization programs to children and food handlers locally; and

• To expand Clark County Health District tobacco control and education program.

Mr. Rowles then endorsed the comments of and yielded the floor to the next speaker, Jim Begbie.

Chairman Freeman thanked Mr. Rowles and said she might call on him to make another presentation to the standing interim health committee.

Jim Begbie, acting district health officer, Washoe County, noted there had been a number of impacts on budget reductions over the years and aid-to-counties was the largest one they had experienced. Washoe County provided about 50 percent of revenue through tax transfers. The county had treated them very fairly over the years, providing funds when available to meet or increase service levels. When revenues declined, his district had to make reductions as well. In the current fiscal year they had to take a $300,000 reduction in the tax transfer from the county and those reductions were made in the infrastructure. Consequently, there was less staff available in many areas.

In times of budget cuts the district had to change its focus in its work, such as by not meeting the mandated food service inspections, which they made on an average of one to two times per year. The Board of Health had mandated food manager certification and improved scores had resulted. However, inspection presence was still required to ensure continued compliance with regulations.

Mr. Begbie provided his written testimony and the Washoe County District Health 1997/98 Annual Report (Exhibit H). Among items covered were:

• Significant budget cuts;

• Washoe County funding support for public health;

• Budget reduction Plan (Fiscal year 98/99) was an example of shared reductions;

• Legislative support for public health;

• What had been done when revenues had decreased or not kept pace with need;

• Yearly statistical data; and

• Department public health goals and progress report.

Prevention was extremely important in public health, as Dr. Guinan and Mr. Rowles pointed out. In Washoe County they tried to target the leading causes of disease, that was where public health needed to go. What Mr. Begbie's district had done was to eke out sources within the organization by trying to find community collaborators and partners to see if the district could move its services, or they could work together.

Due to the short time remaining for the meeting, Mr. Begbie touched only briefly on the many programs ongoing in Washoe County; however, those were discussed in detail in Exhibit H.

Mr. Begbie stated they were public health professionals dedicated to providing the best public service possible with the cards or funding they were dealt. Their strategy had always been to do all other reductions first before reducing program services. Absent additional funding they had not been able to target the root causes of illness and death in the communities, and that was the direction for public health. The 10 leading causes of death in Washoe Health District were:

• Heart disease
• Cancer
• Diseases of the lung
• Stroke
• Suicide
• Pneumonia and influenza
• Other accidents and adverse affects
• Liver disease and cirrhosis
• Motor vehicle accidents
• Diabetes

The community expected the health districts to take the lead and address those issues, but due to lack of infrastructure they were not able to meet that expectation. He added providing data and information to the community was an important role; it was not always available. Recently he had been requested by a Health Maintenance Organization (HMO) in the community to get information on selected populations. That would have been helpful to them in targeting health care issues. The information was not available. He had also received a request from Nevada Healthcare Coalition to meet with the wellness team which, he noted, had been created out of those eked out resources mentioned earlier. They would be asking for data that was not available. That was where public health needed to go. Dr. Guinan talked about doing research; research produces data, with data good decisions could be made.

A summary of Washoe County Health District's 22 goals for the year 2000 was included in the packet (Exhibit H). Their mission was to pursue health promotion, disease prevention, and environmental protection. However, for those and many other important goals and public health challenges, such as locating and disabling drug labs which posed a great threat to the community, no funding was available. It was hoped that when the proceeds from the tobacco settlement finally became available, it would be used to fund those vital programs.

Chairman Freeman noted, in regard to drug houses, she lived in an older residential section of Reno near the university, and the numbers of drug houses found in her district recently had increased enormously.

Mrs. Freeman said she was unsure how the tobacco money would be handled in the interim; however, she wanted the health districts to be able to "get their oar in the water" early. She added she would see what could be done, but would also need their help.

Mr. Rowles said even if not from the tobacco money, there was an issue in which the legislative finance committees did approve a priority should additional state dollars become available, that aid-to-counties would be one of the top items for consideration. Mrs. Freeman explained she had not realized or understood the kind of impact that would have back in 1991 when it happened. It was serious and terrible that the reduced per capita had never been restored.

With no further business before the committee, Mrs. Freeman adjourned the meeting at 3:40 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: