ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES

MINUTES OF THE meeting

of the

ASSEMBLY Committee on Health and Human Services

Seventy-First Session

March 7, 2001

The Committee on Health and Human Serviceswas called to order at 1:30 p.m., on Wednesday, March 7, 2001. Chairman Ellen Koivisto 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. Ellen Koivisto, Chairman

Ms. Kathy McClain, Vice Chairman

Ms. Sharron Angle

Ms. Merle Berman

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Bonnie Parnell

Ms. Debbie Smith

Ms. Sandra Tiffany

COMMITTEE MEMBERS ABSENT:

Mrs. Vivian Freeman

Mr. Wendell Williams

GUEST LEGISLATORS PRESENT:

Assemblyman Dennis Nolan, District 13

STAFF MEMBERS PRESENT:

Marla McDade Williams, Committee Policy Analyst

Darlene Rubin, Committee Secretary

OTHERS PRESENT:

Gene Segerblom, former Assemblywoman, District 22

Sean Nebeker, Vice President, TMA Advertising

Kelly B. Quinn, EMS Field Representative, Clark County Health District

Stephanie Beck, R.N., EMT Coordinator, Washoe County District Health

Chris Ferrari, Issues Manager, The McMullen Strategic Group

Jon Sasser, Statewide Advocacy Coordinator, Covering Kids Coalition

Charles Duarte, Administrator, Health Care Financing and Policy

Bill Welch, President/CEO, Nevada Hospital Association

Jan Gilbert, Lobbyist, Progressive Leadership Alliance of Nevada (PLAN)

Bobbie Gang, Nevada Women’s Lobby

Elizabeth Pederson, League of Women Voters

Chairman Koivisto opened the hearing on A.B. 173 and announced the legislation was brought forward in order to make some minor changes to legislation brought forward by then-Assemblywoman Gene Segerblom, District 22, in a previous session.

Assembly Bill 173: Expands circumstances under which emergency life-resuscitating treatment may be withheld from patient in terminal condition. (BDR 40-437)

Assemblyman Dennis Nolan, District 13, sponsor of the bill, asked Ms. Segerblom, the original sponsor, to comment.

Former Assemblywoman Gene Segerblom, Henderson, Nevada, said she had worked on the bill for many years and was very much in favor of the amendments recommended. She noted that the “Do Not Resuscitate” bracelet could not be put on another person. “If you don’t like someone you can’t get them a bracelet.”

Mr. Nolan supported Ms. Segerblom in her past efforts to bring forward “Do Not Resuscitate”(DNR) legislation since 1995. He had testified on her bills and even brought his own bill on the issue, all based on his own experience as a paramedic with a 15-year career providing pre-hospital care and training. He had a great deal of experience working in the field when there were no DNR orders. He explained about responding to the home of a person who may have been diagnosed with a terminal disease and was at the end stage. Quite often the family, no matter how well prepared they might be, did not know what to do when sometimes the end did not happen in the way the doctor said it would. Prior to DNR orders there was nothing legally that prevented the pre-hospital care providers from not resuscitating a person who was at the end stage of a very long and debilitating disease; they were ready to go but the law had not provided for that. In 1995 and again in 1997, bills were brought forward to implement DNR orders in line with what most other states had done.

Mr. Nolan informed that A.B. 173 had been prompted by experience with the DNR law in that there seemed to be some minor loopholes. Numerous people from Clark and Washoe Counties and others would offer testimony, the intention of which was to correct those small problems: specifically, the response of paramedics to the scene, and the transfer of patients who had been deemed terminally ill and had been provided with the DNR order from one facility to another. It was the transfer component that had become a problem. Further, they determined there needed to be some additional language with respect to pediatric patients.

Mr. Nolan explained the bill had been drafted prior to some additional amendments, entitled DNR – Pediatric Patients (Exhibit C), being proposed by the Clark County Health District and supported by Washoe County and the Regional Emergency Medical Services Authority (REMSA). Additionally, at the instant meeting he had been given two more amendments; one on behalf of REMSA (Exhibit D), and the other, from MedicAlert (Exhibit E).

It was important, Mr. Nolan said, when resuscitating a person who had a DNR order, to understand what was involved. A DNR order was not issued capriciously; there were legal questions to be answered with a great deal of thought by the medical community, the family, and the patient. If a DNR order was not honored then the process of resuscitation by the paramedics had to begin. As a person began to expire usually their respiratory effort would fail first. To correct that the paramedics had to intubate the person which involved putting a very large tube either down their throat or through their nose and down into their throat. A bulb was then inflated in the windpipe to keep the tube in place. Often that bulb caused damage to the trachea. Even when it was done in a hospital setting it was a traumatic scenario.

Further, he said, if there was cardiac failure it was necessary to start very large “IVs” because staff anticipated administering a great deal of medication and drugs. They looked for the largest vein, if not in the arms then in the neck. Cardio pulmonary resuscitation (CPR), which involved manual chest compressions, was started if the heart failed. For an older or frail person it was almost impossible to do that procedure without fracturing ribs or separating cartilage in the chest. If the person survived that, there would be all types of complications and severe pain, even in just trying to breathe on their own. He added it would be unfortunate for a terminally ill person to end their time on earth in that manner. Mr. Nolan explained the process so it would be understood just how important it was that the bill passed to protect the patient’s rights

Sean Nebeker, representing the Clark County Health District, expressed strong support for A.B. 173 with two minor amendments that Assemblyman Nolan had spoken of. She then introduced Kelly Quinn, EMS Field Representative, for the Clark County Health District.

Mr. Quinn reported the district had three issues they felt warranted discussion:

· The facility transfer issue, which had been addressed as currently written. The problem found in the statute was that a pre-hospital care provider could not honor charted DNR identification if they were going to transport to a nursing home or another facility. They had to have one of the currently issued forms. Mr. Quinn wanted to remedy that so that a charted DNR identification could be honored in the absence of the form currently issued.

· Regarding pediatric patients, the statute currently did not allow anyone under 18 years of age to receive a DNR identification. The proposed language in Exhibit C would allow that to happen. The parent or legal guardian working with the physician to apply for the identification, however the parent or guardian, or the patient himself, could revoke that identification.

· The MedicAlert-type identification provided more enabling language that would allow the two boards of health to adopt regulations that permitted entering into an agreement with MedicAlert or a similar type company to issue a bracelet. Currently the statute required the two health authorities to issue that bracelet and neither did. It was a “jewelry issue” and neither wanted to get into that business. Therefore, the proposed agreement would enable the current form to be issued and the patient could take the form and apply to MedicAlert or other such company and receive their identification that would be approved by the board of health.

Chairman Koivisto asked about the current process to get a bracelet. Mr. Quinn responded that the patient had to be diagnosed terminally ill by their attending physician; they had to be 18 years of age or older; and, they submitted an application to the Clark County Health District or the Nevada State Health Division, through the Emergency Medical Services (EMS) office. Thereafter, a new salmon-colored form was issued and mailed to the patient. Mrs. Koivisto asked if the patient could then get the bracelet. Mr. Quinn said “no,” currently that form was their DNR identification. If an ambulance was called for whatever reason, the pre-hospital care provider would arrive and if the patient was being treated for something else, for example, a broken arm, the patient would produce that card so that if they did go into cardiac arrest resuscitative treatment would be withheld. If the patient was unconscious, in cardiac arrest, for example, then the family members would have to produce the card for the ambulance attendants and life resuscitative treatment would be withheld.

Assemblywoman McClain asked why the health districts simply did not issue a request for proposal (RFP) and have the bracelets made available. Mr. Quinn responded they had tried doing that however, the way the statute was currently written, the identification had to be issued by the health authority and that authority could not be relinquished to another company. Counsel on both sides had indicated probably that could be done if the applications and the money went through the health authority, who in turn would send it to the vendor, the vendor returned the bracelet to the health authority who would mail it to the patient. The health authority did not want to do that. The goal was for the patient to deal directly with the vendor.

Mrs. McClain asked who the counsel was. Mr. Quinn said it was Steve Minagil for the Clark County Health District, and the Attorney General’s Office was involved in 1997.

Assemblywoman Leslie said the pediatrics issue was a major change. She noted earlier testimony that stated 24 states had parental consent, and asked Mr. Quinn if that had been an issue in Nevada. Mr. Quinn said it had become more of an issue because regulations were being implemented. The entire program, as a result of A.B. 29 in the Sixty-Ninth Session,that established a procedure that authorized qualified patient to choose not to be resuscitated in event of cardiac or respiratory arrest, had not become implemented until the fall of 1999 in the division, and in the spring of 2000 at the health district. Due to the regulation process and the protocol it had only been implemented in Clark County in the last few months.

Mrs. Leslie asked if parents were requesting it. Mr. Quinn said primarily physicians had requested it. Mrs. Leslie then asked about the revocation; could a four-year-old revoke the order. Mr. Quinn was not able to answer that. However, in concept the patient would be able to revoke the order. Mrs. Leslie hoped there would be more testimony on the issue. She was not necessarily against it, she stated, but felt somewhat uncomfortable that it was a step further than was necessary. Mr. Quinn pointed out the children were the terminally ill pediatric population. Mrs. Leslie understood that, but added that when discussing life-and-death situations it was something to be considered very carefully. She reiterated the need for more information; why it was necessary, and why the physicians felt it was necessary. She was simply not comfortable with the issue at it stood.

Chairman Koivisto asked Mr. Quinn if he would be able to obtain information from physicians. Mr. Quinn said he would and, in fact, had requested a video-conference at the Grant Sawyer Building simultaneous with the meeting but it had not been available but, had it been, there were physicians who were going to testify. Mrs. Koivisto asked Mr. Quinn to have those physicians submit letters to the committee. She advised the bill would go into a work session.

Stephanie Beck, R.N., EMS Coordinator, Washoe District Health Department, reported she had appeared in three prior legislative sessions in support of the DNR bill. The district supported the legislation to remedy the problem in regard to the transfer issue, and she noted REMSA had minor language changes that would make the directive even clearer. The proposed wording “prepared for or during transfer”(Exhibit D), she explained, was important because sometimes on arrival at a nursing home, the patient might go into cardiac arrest before they even left the facility. Regarding the pediatric issue, it was something new and she could not address that, but understood, too, it needed further discussion. However, as a point of information, she had spoken to physicians within the health department and to other people at Marvin Picollo School, where some of the children had very severe disabilities and terminal illnesses with chronic seizure disorder, and there had been parents who had asked for DNR orders and inquired about that issue.

Chris Ferrari, representing Regional Emergency Medical Services Authority (REMSA), who was the contract emergency service provided for Washoe County. REMSA supported A.B. 173, and although life and death was a difficult issue to deal with, the bill gave validity to a decision between the patient and the doctor that had been predetermined. The bill allowed an emergency medical technician (EMT) to carry out an order of an individual who had made the decision with their medical professional. He noted a small amendment (Exhibit D) and, as stated earlier, the intent was to further clarify when the actual transportation began and allowed the EMT to honor the decision between the doctor and the patient. Mr. Ferrari noted he would be happy to work with Mr. Quinn and his group.

With no further discussion on the measure, Chairman Koivisto closed the hearing on A.B. 173 and said the bill would be held over for a work session for further testimony.

Chairman Koivisto turned the meeting over to vice chairman McClain and moved to the witness table.

Vice chairman McClain opened the hearing on A.B. 196.

Assembly Bill 196: Prohibits department of human resources from considering assets of child or pregnant woman or family of child or pregnant woman to determine eligibility for child health assurance program. (BDR 38-224)

Assemblywoman Ellen Koivisto, District 14, reported the measure had come from the Legislative Committee on Health Care, which she chaired during the 1999-2000 interim. Members of the committee at the June 6, 2000 meeting adopted the measure. Mrs. Koivisto explained the bill prohibited the Department of Human Resources (DHR) from considering the resources or assets of certain persons when they applied for services from the Child Health Assurance Program that was administered by the Nevada Medicaid program.

As background, the committee members might note that members of the Legislative Committee on Health Care adopted the identical recommendation during the 1997-1998 interim and it was ultimately introduced as A.B. 4 of the Seventieth Session, that prohibited department of human resources from considering assets of child or pregnant woman or their families to determine eligibility for child health assurance program.

Mrs. Koivisto pointed out that as with other measures adopted by the committee during 1999-2000 interim, they had depended upon staff of the DHR to provide estimates concerning the cost of implementing the proposal. The associated costs, as reported to the committee during the interim, were identified in Section 4.

Jon Sasser, Washoe Legal Services, and state cochairman of the Nevada Covering Kids Coalition, stated the elimination of the assets test was the most important item in the legislative agenda for the Covering Kids Coalition for the session. Mr. Sasser provided his written testimony (Exhibit F). He highly recommended the passage of A.B. 196. He noted with pleasure the Governor had included funding for the proposal in his budget and, as Assemblywoman Koivisto noted, the last two interim legislative committees had recommended it.

Mr. Sasser explained the Nevada Children’s Health Assurance Program (CHAP) came into being in 1988 when Congress was trying to expand health care to pregnant women and low-income children, and it required states that participated in the Medicaid program to provide Medicaid to children under age six whose incomes did not exceed 133 percent of the poverty level, and to children above age six whose incomes did not exceed 100 percent of the poverty level, and also for pregnant women in families with incomes below 133 percent of the poverty level. States had the option to consider not only the amount of income people had but also the amount of assets. In 1988 Nevada chose not to consider assets. The assets test in Nevada came into being in 1992, as a revenue saving measure, in the budget crunch faced that year due to revenue shortfalls. Nevada was one of only eight states that imposed an assets test.

The assets test states that a household with one person could not have countable assets or resources exceeding $2,000 in value. A family of two could not have assets over $3,000, and for each additional family member $150 was added to the assets up to a maximum of $4,200.

Mr. Sasser reported that administering the assets test was not as simple as it might seem, however, the assets test policy (Exhibit G) from the Welfare Manual, was 28 pages in length and 40 different kinds of assets or income, some of which counted in whole, in part, or not at all. As an example, the first $1,500 of a savings account for burial expense would be allowed. The test was complicated to administer. The reason for eliminating the assets test was, in part, timing. Congress had made additional changes to offer incentives to states to cover children. It ruled that states could either start their own children’s program; which Nevada had done with Check-Up, or it could expand the Medicaid program. As an incentive, Congress said it would pay 65 cents on the dollar or an enhanced federal match. Thus, by eliminating the assets test the state had allowed over 3,000 children on Check-Up that would not otherwise be there.

Another reason, Mr. Sasser said, for eliminating the assets test would be to allow additional pregnant women to come on the program, 247 in the first year and 342 in the second year, that otherwise would not have access to the important prenatal care they needed as well as payment for the delivery of their child.

Moreover, by eliminating the assets test a great deal of red tape was also eliminated. There would be no need for an eligibility worker in the Welfare Division to go through the 28-page regulations. Also, there was a connection between the Check-Up program and the Medicaid program. For example, when an application was sent to Check-up and the staff made a determination that the income might be low enough for Medicaid, the applicant would be referred to Medicaid as well, and that meant going through an evaluation of the assets. For the last 12 months that that had been done there were 1,700 referrals to have Medicaid eligibility determined, which led to only 85 people actually getting Medicaid. Approximately 1,600 went through the red tape only to be rejected for Medicaid. The assets test was a considerable waste of time for everyone.

Finally, Mr. Sasser pointed out, if greater progress was to be made in those programs, eliminating the assets test was essential for either expedited eligibility for pregnant women within seven days, as proposed by the Governor, or presumptive eligibility as adopted by the committee at the meeting of February 28, 2001. An assets test made it very difficult for those systems to work; because within seven days a decision had to be made and going through those 28 pages of rules and regulations precluded efficiency in determining expedited eligibility. In the case of presumptive eligibility, payment was being made for medical services for someone who might not be qualified or had not followed through on those complicated rules and regulations.

There had been discussion on an interactive Web-based application for Check-Up, also in the Governor’s budget. But there again, if extensive verification had to be provided on the value of assets, or whether one met the exception to any number of rules, that made that system, which hypothetically could find one eligible in six minutes, very unworkable because of all the paperwork that had to be submitted. The Governor had proposed in his budget approximately $5 million for uninsured families. It was Mr. Sasser’s understanding the Welfare Division would like to use that money to attract the enhanced 65 cent federal match by running it through the Check-Up program and allowing coverage for parents. In order to get such a waiver, a state must meet a test where three out of five preliminary factors were complied with, one of which was whether there was an assets test. Without meeting that, Nevada would not be able to qualify for that extra money.

Finally, Mr. Sasser added that the Covering Kids Coalition had been trying to develop a joint application between Check-Up and Medicaid for some time, however, that had not been able to be done because Medicaid required all the information about assets that was not required for Check-up.

He added that Charles Duarte, Health Care Financing and Policy, who would be testifying next, had allowed him to review the fiscal note. Mr. Sasser believed in the assumptions in that fiscal note and felt it was correct and accurate. The only difference, Mr. Sasser believed, was that Mr. Duarte would want to have the assets test eliminated but not by statute, rather by changing the state plan. A change in the law was not needed to eliminate the assets test. Conversely, Mr. Sasser felt the committee’s job was to send a message to the Committee on Ways and Means this was important public policy and good health policy for the state.

In summation, for all the reasons detailed, Mr. Sasser asked the committee to pass A.B. 196.

Assemblywoman Leslie was glad Mr. Sasser noted that a state plan change could be done, and it probably should have been done long ago. She added they would look at that in the Committee on Ways and Means; meanwhile it was important to send the message. Another issue, one raised by news media recently, was how to be sure middle- to upper-income people would not use the elimination of the assets test as a way to get into the Medicaid program.

Mr. Sasser said middle- to upper-income people whose incomes fell below 200 percent of poverty could get onto the Check-Up program because they were eligible for it, and no one would ever look at their assets. It was a question of whether they would get Check-Up or Medicaid, which now with the enhancement of 65 cents on the dollar it would not matter much to the taxpayer. Both programs required verification of income; Medicaid required more verification than Check-Up, which only required two pay stubs. The major advantage for some people was that Medicaid would go back and pay bills up to three months prior to application, whereas Check-Up was only a prospective program.

Mrs. Leslie asked if theoretically someone could put their money into assets, then with the elimination of the assets test could qualify. She reiterated she had been asked that question. Mr. Sasser responded the issue was could one afford health insurance or not. If someone had $1,500 in the bank would they purchase health insurance for their children; the most likely answer was “no.” If they had income over the limits, then Medicaid could verify that with access to employment security records and other computer checks to determine if income was being hidden. It was not a major concern. Mrs. Leslie asked if other states had encountered any problems in that regard. Mr. Sasser had not heard of any such problems, nor had there been problems when Nevada had an assets test between 1988 and 1992. But, he added, only about 1 percent of the applicants were disqualified for that reason.

Charles Duarte, Administrator, Division of Health Care Financing and Policy (HCFP), said the Department of Human Resources (DHR) was grateful to the Legislative Committee on Health for recommending what he believed was the most important part of the Medicaid plan for children: the elimination of the assets tests in the CHAP program. As Mr. Sasser pointed out, the CHAP program was included in the Governor’s budget for Medicaid. Regarding the amount in the budget, HCFP had identified $3.3 million for the fiscal year 2002 and $7.4 million in fiscal year 2003 as the amounts necessary to implement the program. A major difference between fiscal notes developed last session and now was the anticipated migration of Nevada Check-Up children to Medicaid as a result of the eligibility change. Mr. Sasser, he said, had addressed that very well, in that a large number of children, approximately 2,500, had been identified as having incomes below 100 percent of the federal poverty limit and were in Check-Up. It was his understanding they were there primarily because of having assets. Once that was removed, the federal government required that on redetermination of eligibility in Nevada Check-Up those children be moved into Medicaid where they belonged. The benefit and another part of the difference in fiscal notes was that there was a 65 percent match on both programs; that meant there was no loss to the state in terms of General Fund.

Additionally, Mr. Duarte added, the Governor’s budget included funds to develop an expedited eligibility unit for pregnant women. The expenditure for eliminating the asset test did have some additional eligibility caseworkers to help process the extras that would result. However, those were small additions to the overall amount in the budget. His testimony was provided as Exhibit H.

As Mr. Sasser indicated, the HCFP did have some concerns about putting Medicaid policy into statute, but the committee had already discussed that. He reiterated gratitude for the committee’s recommendation to eliminate the assets test and a major reason why it had been included in the DHR budget.

Assemblywoman Berman asked how eliminating the assets test increased enrollment for children. Mr. Duarte responded that the major issue at present was the onerous eligibility policy that made it difficult for families to get children into coverage. In reviewing statistics on the number of applications for the CHAP program and the numbers that dropped out of the process as a direct result of what was called “non-cooperation,” approximately 60 percent of the applications submitted ended up not being processed because applicants elected or chose not to complete the process. Simplifying the policy, added Mr. Duarte, will make it easier for children to come directly to Medicaid for health coverage. Also, there would be children going into the program from Nevada Check-Up who would otherwise be in Medicaid if it were not for assets.

Ms. Berman asked about the impact if the bill did not pass. Mr. Duarte said the benefit of the situation as it was currently was that the proposal was included in the Governor’s budget. Therefore, if it did not pass it was still in the budget and there would be a second chance at making sure it happened.

Assemblywoman Parnell cited A.B. 196 in which the fiscal note stated, “contains appropriation not included in the Executive Budget,” therefore, she asked if that needed to be amended so as not to give the wrong impression. Mr. Duarte believed it should be amended.

Bill Welch, representing the Nevada Hospital Association, expressed support for the elimination of the asset test, whether through A.B. 196 or through the Governor’s budget. The association felt it was an important issue that needed to be addressed.

Jan Gilbert, representing Progressive Leadership Alliance of Nevada, expressed enthusiastic support for A.B. 196. The group believed it was the most important bill for them this session as far as health care. She realized there might be a temptation to say it need not be passed because it was in the Governor’s budget, however, she had heard over and over about the budget shortfall, about cuts that would be made, and so on, and that bill was crucial for covering pregnant women and children. Ms. Gilbert noted she had come before the committee many times and urged elimination of the assets test and it became more and more evident to her how important it was to the community to get people covered. Ms. Gilbert added that a family could have a life insurance policy and it could be counted as an asset and thereby preclude them from coverage.

Finally, she said, an eligibility worker had come to the Committee on Ways and Means in a session past and brought a little red wagon with all the policies and procedures they had to consider when processing an individual through the program. It made one realize how much work they had to do that was unnecessary. If that one step was eliminated it would make things much easier for the eligibility worker.

In closing, Mrs. Gilbert urged passage of A.B. 196 and to send it on to the Committee on Ways and Means.

Bobbie Gang, representing the Nevada Women’s Lobby and the National Association of Social Workers, Nevada Chapter, said both organizations strongly supported A.B. 196. They saw the assets test as a barrier that had kept many children and pregnant women from the final stage of eligibility for both Medicaid and Nevada Check-Up, and they would like to see more people enrolled and enrolled more quickly. Ms. Gang noted that the assets test was the one barrier that prevented the state from having a seamless system that could process the two applications or hopefully, eventually, one application form more quickly.

Vice Chairman McClain said that even if it was in the Governor’s budget, would it not still be necessary to pass the bill to make sure it was funded. Mr. Duarte said he believed that as long as it was in the Governor’s budget it was an appropriate vehicle for the legislature to push it through. Ms. McClain asked if it would not strengthen the committee’s position even more. Mr. Duarte did not feel the committee needed his guidance on that.

Ms. McClain reiterated her belief that a policy committee made policy, and when it reached the Committee on Ways and Means they should find the money to carry out that policy.

Elizabeth Pederson, representing the League of Women Voters of Nevada, noted ample testimony had been heard as to why A.B. 196 was a good piece of legislation. The league supported the bill.

With no further discussion, vice chairman McClain closed the hearing on A.B. 196 and turned the meeting back to chairman Koivisto.

Chairman Koivisto advised that A.B. 196 would be scheduled for a work session. With no further business before the committee, the chair adjourned the meeting at 2:31 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin

Committee Secretary

APPROVED BY:

Assemblywoman Ellen Koivisto, Chairman

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