SENATE COMMITTEE ON FINANCE

MINUTES OF THE MEETING OF THE

JOINT SubCommittee on HUMAN RESOURCES / K-12

OF THE

SENATE committee ON FINANCE

AND THE

ASSEMBLY COMMITTEE ON WAYS AND MEANS

Seventy-First Session

February 15, 2001

The Joint Subcommittee on Human Resources/K-12 of the Senate Committee on Financeand the Assembly Committee on Ways and Means was called to order by Chairman Raymond D. Rawson at 8:06 a.m., on Thursday, February 15, 2001, in Room 3137 of the Legislative Building, Carson City, Nevada. The meeting was videoconferenced to the Grant Sawyer Office Building, Room 4401, Las Vegas, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

SENATE COMMITTEE MEMBERS PRESENT:

Senator Raymond D. Rawson, Chairman

Senator William J. Raggio

Senator Bob Coffin

Senator Bernice Mathews

ASSEMBLY COMMITTEE MEMBERS PRESENT:

Ms. Christina R. Giunchigliani, Chairman

Mrs. Barbara K. Cegavske

Mr. Joseph E. Dini, Jr.

Ms. Sheila Leslie

Ms. Sandra J. Tiffany

ASSEMBLY COMMITTEE MEMBERS ABSENT:

Mr. David E. Goldwater (Excused)

STAFF MEMBERS PRESENT:

Gary L. Ghiggeri, Senate Fiscal Analyst

Bob Atkinson, Program Analyst

Jennifer Ruedy, Committee Secretary

OTHERS PRESENT:

Yvonne Sylva, M.P.A., Administrator, Health Division, Department of Human Resources

Mary Bryant, President, Friends of Special Children

Cynthia Dutwin, Public Service Intern, Special Children’s Clinic, Health Division, Department of Human Resources

Marcia O’Malley, a private citizen

Terry Phelps, a private citizen

Blandina Reyes, a private citizen

Rosa Waitman, a private citizen

Sarah May, Public Service Intern, Special Children’s Clinic, Health Division, Department of Human Resources

Philip Weyrick, Administrative Services Officer III, Fiscal, Services and Personnel, Health Division, Department of Human Resources

Karl Munninger, Administrative Services Manager, Health District, Clark County

Eileen Coulombe, Administrative Health Services Officer, District Health Department, Washoe County

Janine Hansen, Lobbyist, State President, Nevada Eagle Forum

Lynn Chapman, Lobbyist, Nevada Eagle Forum

Kevin Quint, Executive Director, Join Together Northern Nevada, and Chairman, Bureau of Alcohol and Drug Abuse Advisory Committee

Mary Kathleen Cronin, a private citizen

Kari Demetras, Chief Executive Director of Step 2, and Member, Bureau of Alcohol and Drug Abuse Advisory Committee

Yvonne W. Isola, a private citizen

BUDGET OVERVIEWS

HEALTH DIVISION

HR, Special Children’s Clinic – Budget Page HEALTH-57 (Volume 2)

Budget Account 101-3208

Senator Rawson stated there are numerous people here in Carson City and in Las Vegas who would like to testify on budget account 101-3208, Special Children’s Clinic. He said this budget would be addressed first to accommodate those people wishing to speak.

Senator Rawson said he has received feedback from many concerned citizens over the proposed deletion of the Public Service Interns. He asked Ms. Sylva to clarify the effect of the deletion of these positions on services.

Yvonne Sylva, M.P.A., Administrator, Health Division, Department of Human Resources presented budget account 101-3208. She stated budget account 101‑3208 has 68.01 full time equivalent (FTE) positions. Of those positions, 23.5 FTEs are located in the Reno office and 44.5 FTEs in the Las Vegas office. The budget is supported by the General Fund, insurance recoveries, and the Maternal and Child Health Services Block Grant. Special Children’s Clinics are located in Reno and Las Vegas. She said the clinics “serve as regional centers providing comprehensive family-centered, community-based, multi-disciplinary services to children 0-3 with known or suspected developmental delays.”

E-125 Equitable, Stable Tax Structure – Page HEALTH-59

In regard to the Public Service Interns (PSIs), Ms. Sylva explained the decision to eliminate four positions in Reno and six in Las Vegas was a direct result of the 2001 budget constraints. Ms. Sylva said, “there will be minimal impact to the service delivery system as a result of these reductions.” She stated this was a difficult decision, not an arbitrary one. She stated the clinics provide services which are very expensive, complex and generally not available in the private sector. The clinics currently have a 30 percent “no show rate.” Often, she pointed out, children miss their appointments because they are “fragile” and their medical appointments are their top priority. Ms. Sylva explained the deletion of the Public Service Interns is to maximize limited resources and provide cost-efficient services to the public.

Ms. Sylva indicated she does not believe the proposed budget will affect services. She suggested the Health Division should conduct an internal fundamental review of the clinics to determine who should provide and fund these services in the future. According to Ms. Sylva, the Health Division has requested increased funding each legislative session since at least 1989 to address clinic space, waiting lists, and staffing needs. She said the Las Vegas Special Children’s Clinic pays over $500,000 each year for leased space.

Continuing, Ms. Sylva pointed out that during the 1999 Legislative Session, a transfer of resources from the Maternal and Child Health budget (101-3222) to the Special Children’s Clinic budget was approved. Ms. Sylva explained this transfer of resources was for the sole purpose of reducing waiting lists for initial appointments. No additional funds were allocated to reduce waiting lists for treatment services at the clinics, she added. She said the waiting list for initial appointments is currently one week in Reno and four weeks in Las Vegas. More treatment services were provided in the last biennium than in the previous biennium despite the fact there was no new staff, according to Ms. Sylva. Currently, the waiting list for treatment services is four weeks in both Reno and Las Vegas. The type of professional services needed determines the waiting list for treatment services. She further stated the Public Service Interns act as support staff to the developmental specialists in Las Vegas where the waiting list is just one week.

Ms. Sylva explained the Public Service Interns provide support services to staff professionals who provide group treatment to children ages 0 to 3. Generally, the Public Service Interns “prepare materials, clean the toys, pick up the rooms and often accompany professional staff on home visits into unsafe neighborhoods and also perform clerical activities in the absence of office staff,” according to Ms. Sylva. She said they do not routinely provide direct treatment services. She does not believe the deletion of the Public Service Interns will have any effect on waiting lists or treatment services. Federal requirements for early intervention services now require that treatment services be provided in a child’s natural environment rather than a clinic-based setting, she said. As services move out of the clinic, she believes, the need for Public Service Interns will decline.

Ms. Sylva recommended “the budget be supported as presented along with the fundamental review of the clinics over the biennium, including the investigation of all potential funding opportunities be explored as they relate to maximizing third party reimbursement.” She noted strategic planning funds are included in the director’s budget for the Department of Human Resources to review services to the disabled and further examine early intervention services. Special Children’s Clinic provides 88 percent of those services within Nevada.

Senator Rawson asked how much is included in the strategic planning funding package Ms. Sylva discussed. Ms. Sylva responded the package includes $550,000 of which $350,000 is from the General Fund and $200,000 is matching funds. Senator Rawson asked how much of that package is actually directed toward the budgets Ms. Sylva is presenting. She replied that she was not sure.

Ms. Sylva reiterated it is not her agency’s intent to reduce services at the Special Children’s Clinics. She referred the committee to a chart of the proposed distribution of funds from the deletion of the Public Service Interns that is located in a booklet of performance and workload indicators for fiscal years 2002 and 2003 for budget accounts 101-3101 through 101-3255 (Exhibit C. Original is on file in the Research Library.). She explained the deletion of the interns will result in savings of $386,177 in FY 2002-03.

Ms. Sylva explained how the funds were distributed among three other agencies within the Health Division. Consumer Health Protection, budget account 101‑3194, received $41,243 to continue to permit and license restaurants, dairies, hotels, and motels, to inspect prisons and to inspect shellfish. The Immunization Program, budget account 101-3213, received $210,239, which will enable the state program to fully immunize an additional 985 children. Health Aid to Counties, budget account 101-3209, received $146,035 to ensure the per capita rate of state funds to Washoe and Clark Counties’ health departments remains at 80 cents. The Legislature increased the per capita rate from 55 cents for the 1999-2001 biennium. Ms. Sylva said the funding amounts she cited for the budget accounts of Consumer Health Protection and the Immunization Program differ from the funding map provided in Exhibit C. Ms. Sylva said all the additional funding provided these three agencies is to perform their “core functions of public health.”

Senator Rawson asked how many children have Acquired Immunodeficiency Syndrome (AIDS) in Nevada and whether that is a significant concern in Nevada. Ms. Sylva responded that the Special Children’s Clinic does serve children with AIDS and Human Immunodeficiency Virus (HIV), but she does not believe it is a significant issue for the clinics. She explained there is a HIV/AIDS policy for services to these children within the clinics.

Ms. Leslie explained to Ms. Sylva that she is currently working on “a newborn hearing screening bill.” She said many of the parents she is working with are concerned about the delay in treatment after diagnosis. Ms. Leslie said “if these infants get their hearing aids within the first month of their life as compared to the third month of their life that there is just a huge difference in their development.” She expressed her wish to avoid any cuts to this budget. She said she is concerned that if the bill she is working on passes out of the Legislature, it will identify many newborns with hearing problems but there will be insufficient resources to treat them.

Ms. Sylva said the waiting lists have been a problem addressed during many legislative sessions, yet they persist. Early diagnosis further complicates the issue of the waiting lists, and Ms. Sylva said she does not have a solution. She agrees with Ms. Leslie that it is critical for prompt treatment after diagnosis. The waiting list for initial appointments has been reduced, she added. Ms. Sylva said that after the initial diagnosis, the children could receive hearing aids or further treatment from their private providers. Ms. Leslie reiterated she is very concerned about this issue.

Ms. Giunchigliani questioned whether the Health Division should be involved in both diagnosis and treatment. She suggested the subcommittee further discuss where the Special Children’s Clinic should be placed and properly funded. She indicated she believes the Health Division is too busy to deal with both diagnosis and treatment. She suggested the Division of Child and Family Services or the Division of Mental Health and Development Services could possibly offer the treatment part of the program.

In response to Ms. Sylva’s reference to children receiving treatment by their private providers after the clinic’s initial diagnosis, Ms. Giunchigliani asked whether insurance companies offer benefits for diagnostic procedures. Ms. Sylva responded that insurance does provide coverage for diagnostic procedures, and her agency receives “decent” reimbursement in this area. Ms. Sylva agreed the public might be better served by moving the treatment services programs to another agency. Ms. Giunchigliani asked the subcommittee to further analyze dividing the responsibilities as discussed. She said “if we are doing a good job on diagnostic, then we need to make sure that the treatment follows, and in a timely manner.”

Ms. Giunchigliani asked Ms. Sylva to explain whether the planning funding package totaling $550,000 presented to the committee recently by the Department of Human Resources was for strategic planning or to identify health care needs in Nevada. She pointed out the supporting information regarding goals for this request was insufficient.

Ms. Sylva stated the request was for a complete review of all early intervention programs, including HAPPY (Home Activities Program for Parents and Youngsters), First Step Nevada, Inc., and the Special Children’s Clinics. She explained the request is to study the role of early intervention programs, whether the government is the most appropriate provider, and how these programs should be funded. She indicated concern that third-party reimbursement is not fully realized. She said she thinks the large amount of General Fund support indicates other potential funds have been ignored to some extent. She said she thinks the General Fund money should be used as “match monies to bring in additional federal monies to pay for those intervention services.”

Ms. Giunchigliani asked whether MAXIMUS, a consulting firm who assists in optimizing federal funding, works with the Health Division or solely with the Department of Human Resources. Ms. Sylva responded her division has worked very little with MAXIMUS on this account, but they do assist on other efforts.

Ms. Giunchigliani asked Ms. Sylva whether this matter should be addressed by other specialists or solely by in-house staff. Ms. Sylva stated she does not have sufficient staff to adequately perform the proposed review. She believes other specialists in early intervention programs would be able to provide the necessary assistance.

Ms. Giunchigliani asked whether local governments provide any treatment programs after diagnosis of these children. Ms. Sylva responded that she is unaware of any multidisciplinary treatment programs supported by local governments prior to the child’s entering the public school system. It is very expensive, she added.

Ms. Giunchigliani requested that Health Division staff study early intervention programs to provide specific numbers and to identify additional funding opportunities. Senator Rawson asked Ms. Sylva to work with the Legislative Counsel Bureau (LCB) staff on this review. He explained this request is merely a desire to learn more, not a criticism of Ms. Sylva.

Mrs. Cegavske asked whether the Reno clinic could accommodate parents from Las Vegas who might choose to fly their child to the Reno clinic because of the shorter wait for initial appointments. Ms. Sylva responded this would be a short-term solution before the waiting lists in Reno also lengthened.

Mrs. Cegavske asked whether Ms. Sylva would like to increase federal funding and whether she found the various restrictions for receipt of federal funds cumbersome.

Ms. Sylva responded that the restrictions for The Individuals with Disabilities Education Act (IDEA) Grant are definitely confining. Other federal funds received from the Maternal and Child Health Block Grant funds are fairly unrestrictive, she added. Ms. Sylva stated her division has wondered, at times, whether it would be easier “to tailor their services to best meet the needs of the population.” In response to Mrs. Cegavske’s question regarding increased federal funding, Ms. Sylva stated, it is too soon to know what federal funding will be available because of the new administration. Ms. Sylva said she anticipates the 2000 Census data should result in increased funds from the Maternal and Child Health Block Grant. She did, however, explain that only 30 percent of those funds are allocated for children with special health care needs and the rest of the funds are directed toward other budgets.

Mrs. Cegavske voiced her support for Ms. Giunchigliani’s request for further study and further requested research into other entities, such as non-profits, that may provide similar services. She cited Easter Seals as a good resource in the past, but said she was unaware whether they still exist in Reno. She said she would like to know whether other organizations with early intervention programs, such as Easter Seals, have been terminated and, if so, why they have been. She suggested funding from terminated programs might be identified and re-directed to the Special Children’s Clinic.

Senator Rawson questioned the expense of the capital improvement project. He said there is nearly $2.5 million in the recommendation and it seems very expensive for the square footage and remodel. He said he does not question the need for the project, but he would like the Health Division to work with LCB staff to further define their needs and the associated costs.

Ms. Giunchigliani asked whether the Special Children’s Clinics receives referrals from Family To Family Connection and whether the clinics track those referrals.

Ms. Sylva said the clinics do receive many referrals from Family to Family Connection and other family resource centers throughout Nevada. However, she pointed out, most referrals come from the neonatal intensive care units throughout Nevada.

Senator Rawson welcomed members from the public both in Las Vegas and Carson City to address the Special Children’s Clinic budget. The meeting was videoconferenced to accommodate those people in Las Vegas wishing to testify.

Mary Bryant, President, Friends of Special Children, provided a written copy of her statement (Exhibit D) to the subcommittee. She said she has a six-year-old daughter, Kailin, with Down’s syndrome, who received therapy at the Special Children’s Clinic in Reno, from the age of three weeks to three years. She attributes her daughter’s current success in school to this early intervention. She offered reasons for continuing to fund the Public Service Interns (PSI) positions, to allow the professional staff more time for meaningful therapy and to educate and train future professional staff. She said she believes it would be fiscally detrimental to eliminate the PSIs for many reasons. The first reason is the assumed lengthening of the treatment waiting lists would cause delayed services that would have a detrimental effect on the children’s development. She pointed out this would necessitate more expensive services later in their lives. Secondly, she said, increased waiting lists will result in costly litigation from desperate parents.

Cynthia Dutwin, Public Service Intern, Special Children’s Clinic, Health Division, Department of Human Resources testified from Las Vegas in opposition to the elimination of the PSIs. Ms. Dutwin provided a written copy of her statement (Exhibit E) to the subcommittee. She contended that the PSIs provide direct service and the elimination of the PSIs will have a significant impact on the services provided at the clinics. She stated the following:

In the past two weeks, the Public Service Interns in Las Vegas have independently facilitated 17 of the 74 regularly-scheduled groups. That means we provided the direct service to children in 23 percent of the groups. The children we serve are at a developmental level where consistency, structure, and familiarity are crucial. With the loss of the Public Service Intern positions, the Special Children’s Clinic professional staff, in particular the developmental specialists and the speech pathologists, will have to absorb the Public Service Intern duties into their existing schedules. This means that those professionals each will have to absorb approximately 11 hours per week or roughly 2 hours per day. That translates into one evaluation slot or two treatment slots that will have to be cancelled in order to perform the Public Service Intern duties . . . the waiting lists will grow and services to the children will be reduced.

Senator Rawson told Ms. Dutwin she is among one of the most appreciated group of interns here in Nevada. He asked her to describe her training and internship.

Ms. Dutwin explained she is finishing a Master’s degree in special education. She chose to be a Public Service Intern because of the unique opportunity to work with various developmental specialists and speech pathologists. She said the training is specific, detailed, and intense; it is the best training she has encountered in this field.

Senator Rawson asked whether most of the PSIs are similarly finishing advanced education. Ms. Dutwin responded that was true. Senator Rawson commented that the PSIs’ backgrounds indicate they are clearly capable of doing more than to “simply sterilize instruments.” Ms. Dutwin responded that upon completion of their degrees, the PSIs would like to enter the field as developmental specialists, child psychologists, counselors, or other related professionals.

Senator Rawson asked whether the PSIs are paid positions, and if so, what is the approximate salary range. Ms. Dutwin responded the PSI salary is approximately $28,000 per year.

Ms. Giunchigliani commented that PSIs earn more than a starting teacher. She further questioned whether the university requires an internship for the specialist Master’s program. Ms. Giunchigliani asked whether it is similar to a required student teaching that students must complete before receiving their teaching license. Ms. Dutwin responded affirmatively.

Ms. Giunchigliani asked whether there is any university funding available to offset the cost of the internship. Ms. Dutwin said she was unsure. Ms. Giunchigliani suggested that potential source of funding be explored.

Senator Rawson said, “If we simply eliminate these positions it does have a ripple effect on other agencies.”

Marcia O’Malley, a private citizen, provided a written copy (Exhibit F) of her remarks in opposition to the proposed elimination of the PSIs. She said her three-year-old son, Ian, received early intervention services at the Special Children’s Clinic in Reno until he transitioned into the Washoe County School District’s Special Education preschool program at three years of age. She said she attributes the lifelong success of many of Nevada’s children with disabilities to early diagnosis and treatment through early intervention programs such as those available at the Special Children’s Clinics.

Ms. O’Malley stated that her son benefited tremendously from concepts introduced at a speech and language therapy group conducted by speech therapists and PSIs at the Special Children’s Clinics. She said the PSIs were “invaluable to the speech therapists who had, and still have, overwhelming caseloads.” She stated that PSIs provided significant family support that the professional staff is simply too overwhelmed to provide. The waiting lists are a problem, Ms. O’Malley added.

Ms. O’Malley indicated she believes demand for the PSIs will increase as the Special Children’s Clinics attempts to comply with new standards of IDEA to deliver services in a child’s natural environment. This will require more travel time and result in less time available for direct therapy services, she added.

Ms. O’Malley said the Governor of Nevada set a goal to have all children read by the time they enter third grade. Children with special needs cannot accomplish this goal without early intervention services. She asked that the joint subcommittee remember these children are part of that group when they allocate funds. She testified that she is opposed to the elimination of the PSIs.

Ms. Leslie asked Ms. O’Malley whether any of the services she received through Special Children’s Clinics were available elsewhere in Reno. Ms. O’Malley responded that they were not.

Terry Phelps testified as a private citizen from Las Vegas in opposition of the proposed elimination of the PSIs. She said she has three children with special needs, and she has accessed the Special Children’s Clinic services for eleven years. She informed the committee the Special Children’s Clinic was sued under a provision of IDEA, and the family was awarded approximately $12,000. She stated the waiting lists are illegal under IDEA and many more lawsuits may result from them. She introduced a fellow parent of a special needs child, Blandina Reyes, who testified in Spanish from Las Vegas.

Blandina Reyes spoke as a private citizen of the needs of her two-year-old son, Alejandro Solis. She explained in Spanish that he needs therapy three times a week but he receives it only once a month. She said he frequently suffers from pneumonia because of the lack of movement, which the therapy would provide. She said he needs a great deal of help that she is unable to provide and she appeals to the committee to help him.

Rosa Waitman, a private citizen, said she is also a mother of a special needs child, Celeste, who has benefited from the services of the Special Children’s Clinic. She expounded on Ms. Reyes’ situation. She said paramedics had to take Ms. Reyes’ son to the hospital this past Saturday. Ms. Waitman explained Ms. Reyes’ son suffers from recurring pneumonia because of a lack of physical therapy. Ms. Waitman said Ms. Reyes believes her son deserves better services. Ms. Waitman said she believes her daughter and the rest of the special needs children deserve to receive the services to which they are entitled. She indicated she, too, is concerned about the elimination of the PSIs.

Sarah May, Public Service Intern, Special Children’s Clinic, Health Division, Department of Human Resources, asked for reconsideration of the elimination of the PSIs. She said she believes the PSIs provide a valuable service to the professional staff and the families served at Special Children’s Clinic. She indicated she works at the Reno clinic. She provided written comments (Exhibit G).

Senator Rawson thanked the public for their comments on the Special Children’s Clinic and acknowledged the difficult decisions limited funds create for Ms. Sylva.

HR, Office of Health Administration – Budget Page HEALTH-1 (Volume 2)

Budget Account 101-3223

E-350 Service at Level Closest to People – Page HEALTH-4

Senator Rawson explained that the governor added the Rural Mammography Program to this budget account. He said he agrees it is an important program, but he needs a detailed budget on the program enhancement. He asked that Ms. Sylva work with LCB staff, and he indicated they need this information as soon as possible.

E-900 Transfer from Immunization – Page HEALTH-4

Senator Rawson said that a request to transfer two positions was introduced during an Interim Finance Committee meeting. He said the positions to be transferred were originally created for, and funded by, the federal Information Network for Public Health Officials (INPHO) grant, which is “soft money.” “Soft money” is not long-term funding, he explained. Senator Rawson asked Ms. Sylva to provide LCB staff details for the indirect cost assessment. He stated the committee would like this information to assure them that the indirect cost assessment will generate sufficient revenue in the next biennium and into the future to support these additional positions.

Senator Rawson said there has been a vacant Management Analyst III position since May 12, 2000, and the Governor recommends the continuation of the position. Senator Rawson asked Ms. Sylva whether she thinks the position should be continued and, if so, to explain her reasoning.

Ms. Sylva responded the position in question is the Tobacco Control Manager, which was recently reclassified as a Health Program Specialist. She noted the Health Division was waiting for the reclassification to be completed, and they intend to fill the position in the near future, she explained.

HR, Vital Statistics – Budget Page HEALTH-7 (Volume 2)

Budget Account 101-3190

Philip Weyrick, Administrative Services Officer III, Fiscal, Services and Personnel, Health Division, Department of Human Resources, addressed a position transfer. He stated that on February 8, 2001, at the meeting of the IFC, the Health Division requested the transfer of the biostatistician position from the Vital Statistics budget to the Office of Health Administration, budget account 101-3223. He explained the transfer would shift funding for this position from the Maternal Child Health (MCH) Block Grant to indirect costs in the health administration budget account. The transfer would enable the biostatistician to support data requirements for the entire Health Division, he added.

Mr. Weyrick noted that this transfer became possible when the Health Division’s indirect rate negotiations with the U.S. Department of Health and Human Services were finalized on January 10, 2001. He said the rate was increased from 10 percent to 11.9 percent, thereby increasing annual indirect revenues by $145,000. He added that the transfer would enable the division to utilize the MCH Block Grant funding for a new Health Resource Analyst II position. He explained that this new position would be dedicated to ensuring all the mandatory MCH Block Grant data reporting requirements are followed. He acknowledged that this transfer request had not been included in the budget because the availability of the additional funding was only approved on January 10, 2001. He stated that the Health Division would like to work with the LCB staff to include this decision unit in their budget.

Senator Rawson agreed the Health Division should work with the LCB staff on this issue in an expeditious manner. He further noted there is a vacant position in this budget, and he asked the Health Division to justify to the LCB staff their continued need for the vacant position.

Ms. Giunchigliani asked for further explanation of the intended request for a new Health Resource Analyst II position. Ms. Sylva stated the MCH Block Grant funding saved from the transfer of the biostatistician would be used to fund a new Health Resource Analyst II. The new position would be dedicated to performing statistical analyses for the MCH Block Grant data reporting requirements.

Ms. Giunchigliani asked whether the new Health Resource Analyst II position is a priority for the division. Ms. Sylva responded that it is a priority.

HR, Cancer Control Registry – Budget Page HEALTH-10 (Volume 2)

Budget Account 101-3153

Senator Rawson said he had no questions on the Cancer Control Registry budget.

HR, Health Aid to Counties – Budget Page HEALTH-13 (Volume 2)

Budget Account 101-3209

Karl Munninger, Administrative Services Manager, Clark County Health District provided a written statement (Exhibit H) prepared by Donald S. Kwalick, M.D., Director, Health District, Clark County. Mr. Munninger stated that Health Aid to Counties (HAC) enables Clark County Health District and Washoe County District Health Department to provide core public health functions in lieu of the state Health Division in those two counties. He referred to a pie chart located in Exhibit H, entitled Clark County FY 00/01 State Aid Allocation, to illustrate the distribution of the program’s total funding of $1,150,152. He then addressed the description of services following the pie chart in Exhibit H.

Mr. Munninger explained the services of each of the ten programs, which are outlined in the handout (Exhibit H). Within the program for community nursing, funding will provide 1,300 home visits at approximately $105 each, he pointed out. Within the Maternal and Child Health Program, 2,700 well baby visits will be funded at $68 each. These visits are less expensive than the home visits for community nursing because they are generally conducted in a clinic, he added. He said the Childhood Immunizations Program will provide 30,000 immunizations to 13,000 children at $8 per immunization.

Mr. Munninger stated that the TB (tuberculosis) Treatment Program has succeeded in lowering active cases of TB from 120 cases in 1996 to 68 cases in 1999 and 82 cases in 2000. He explained that, although the active cases have decreased, the caseload has become increasingly difficult to treat because of the increased number of patients with multiple health problems who are resistant to many drugs. Currently, the combined medications and blood level testing for four specific patients is $100,000 each year, he stated. Diabetics require careful blood level monitoring as they do not absorb the drugs well. Mr. Munninger stated this is a very expensive program.

Mr. Munninger said the Transitional Care Program provides comprehensive in-home services to 20 chronic-disease patients per month. He added that most of those patients are human immunodeficiency virus (HIV) or acquired immunodeficiency disease (AIDS) patients. He said another program provides podiatric care to seniors through a foot clinic. Eligibility for the foot clinic is limited to people over 60 years old whose podiatric condition renders them infirmed, and who do not have sufficient financial resources to retain private services. The Sexually Transmitted Disease (STD) Program funds 2,250 patient visits at $95 each, he stated.

Mr. Munninger said the Safe Drinking Water Act Program is testing products from 20 small water companies to ensure water quality. He stated funding for the Air Pollution Control Program provides the salary and benefits for one full-time enforcement officer. The Health Education Program manages a large tobacco cessation program and a new school based health clinic, he noted.

Mr. Munninger discussed relevant performance indicators included in Exhibit H. The first relevant indicator he mentioned was the reduction of total syphilis cases to five cases in 1999 and four cases in 2000. The second indicator he noted was the reduction of low birth weight babies from 7.4 percent in 1997 to 6.6 percent in 2000. The third indicator he cited was the reduction of the infant mortality rate to 6 per 1,000 live births in 2000 compared to a national average of 7.2 per 1,000 in 1998. The fourth indicator he stated was the reduction of carbon monoxide “exceedances” from 41 in 1985 to none in 1999 and 2000. Consultants working with Health Aid to Counties will provide additional performance indicators in the future, he added.

Mr. Munninger referred to the Emergency Medical Services (EMS) program to illustrate how much the Clark County Health District saves the state Health Division by providing the EMS program. He explained that if the total cost of the EMS program provided by the state Health Division to sixteen Nevada counties were pro-rated and applied to Clark County, it would result in a cost of $1.3 million. This, he pointed out, is more than the total funding in the Health Aid to Counties budget. He added that there has never been a consumer price index factor applied to the Health Aid to Counties funding, and over the past decade, inflation has been approximately 26 percent. He stated the per capita rate was established at $1.10 in the early 1990s, so when this rate is adjusted for inflation over the past decade, it would result in a per capita rate of $1.39. This hypothetical rate adjustment would equal $840,000 more than is currently budgeted, he concluded.

Mr. Munninger explained specific funding pressures for Health Aid to Counties (Exhibit H). The American Academy of Pediatrics and the Center for Disease Control now recommend both Hepatitis A and Prevnar pneumococcal vaccinations be provided to young children. He stated, “Some of those costs can be covered by the vaccine for children program, but if we are to universally administer these vaccines, we are facing an unbudgeted shortfall of a $1 million just for those vaccines.”

The second funding concern Mr. Munninger cited is an unfunded mandate of the Occupational Safety and Health Administration (OSHA) to purchase new safety needles at an additional cost of $120,000. HAC has also lost annual revenue of $200,000 because of a mandatory shift of eligible Medicaid recipients in the Las Vegas metropolitan area to health maintenance organizations (HMOs). Another issue of funding concern, he stated, is that Clark County Health District pays $160,000 annually for poison control hotline services, which are usually funded at the state level in many states.

Eileen Coulombe, Administrative Health Services Officer, District Health Department, Washoe County, provided an informational packet (Exhibit I. Original is on file in the Research Library.). The packet included the 1999-2000 annual report and funding allocation graphs for the Washoe County District Health Department. She explained that a new full-time environmentalist trainee position was supported through the additional $83,000 received from the per capita rate increase. This new position will issue permits to facilities and will allow for increased regulatory enforcement activities. The increased funding further supported the addition of a software application specialist in the administration area to support programs the information technology department does not support. Ms. Coulombe said additional funding was also provided to the Immunization Program.

Ms. Coulombe requested reconsideration of the $1.10 per capita rate that would result in additional funding of $204,681 over the biennium for the District Health Department of Washoe County. She explained that Kafoury Armstrong & Co. conducts an annual external audit to ensure all funds are managed responsibly. Two external consultants, contracted yesterday by the District Health Department, will be performing a capacity assessment and internal review of the department, she added.

Senator Rawson said that to increase the per capita rate to $1.10 would cost an additional $580,000 annually. He indicated the General Fund would be the only possible source of funding for this increase and he doubts the pollution control account has sufficient funds remaining.

Senator Raggio said that following the Governor’s recommendation, the reserve in the pollution control account will decrease to approximately $500,000. He pointed out this Health Aid to Counties budget account is already receiving a small amount of funds from the pollution control account, so any additional funds must be appropriated from the General Fund. He inquired what other sources of funding are available to Clark County Health District and Washoe County District Health Department. He said he believes the two counties are currently more financially capable of providing additional funds than the state.

Mr. Munninger stated the Clark County Health District is “approximately one-third funded by local property taxes, one-quarter funded by regulatory revenue, 14 percent by direct federal grants, 9 percent by federal grants distributed through the state Health Division, 8 percent through state funding.” Senator Raggio interrupted him to request his total budget amount.

Mr. Munninger replied that the total budget for the Clark County Health District is $43.842 million for the current fiscal year.

In response to Senator Raggio’s question, Ms. Coulombe referred to page three of Exhibit I, which identifies the revenue sources for the total 1999-2000 fiscal year budget of $14,264,337. She named the following revenue sources and their corresponding percentage of the total budget: county tax transfer at 45 percent, direct federal support distributed through the state at 18 percent, direct federal grants at 7 percent, service charges and permit fees at 20 percent, state appropriations at 8 percent.

Senator Raggio asked whether the two counties use the Health Aid to Counties funds to “leverage” federal funding.

Mr. Munninger confirmed the HAC funds are used to match federal funds. In the past the funds were nearly an equal match, but many of the current programs have only a 20 percent federal funding match, he added.

Senator Raggio explained it would be “extremely difficult” to increase the per capita rate this biennium in view of the budget constraints and insufficient funding for other critical programs. He stated that it would be unwise to allocate any more funds from the pollution control account.

HR, Consumer Health Protection – Budget Page HEALTH-15 (Volume 2)

Budget Account 101-3194

Senator Rawson asked Ms. Sylva to provide details on a bill that may be introduced to move the responsibility for all dairy inspections from the Bureau of Health Protection Services to the State Dairy Commission, Department of Business and Industry.

Ms. Sylva responded that the State Dairy Commission requested the bill that Senator Rawson referred to, and that it has not been introduced at this point.

Senator Rawson asked whether this transfer of responsibilities would necessitate a transfer of personnel to the State Dairy Commission.

Ms. Sylva responded that the State Dairy Commission does not have a rating survey officer, and the State Dairy Commission has approached the one employed by the Bureau of Health Protection Services. She said she believes the Bureau of Health Protection Services rating survey officer is not considering a transfer to the State Dairy Commission. She further added it is difficult to hire trained rating survey officers, as there is high nationwide demand.

Senator Rawson voiced his concern that the loss of personnel to the State Dairy Commission would have a negative effect on the workload for the consumer health protection office. Ms. Sylva pointed out the bill draft request proposed by the State Dairy Commission does not include any transfer of personnel. She said the commission wants to create a new program with new positions, but she recommended discussing this issue with the State Dairy Commission for more accurate details. She said consumer health protection spent a full year training a new rating survey officer after the previous one resigned during this past biennium. The void created during the training period was detrimental to their efficiency, she added. She said another employee is being cross-trained in this area to avoid recurrence of this problem. Consumer health protection has only 1.5 employees in their dairy program, so they cannot lose anyone from this program, she said.

Senator Rawson stated the bill draft in question would be reviewed closely. He also acknowledged the position vacancy within the Consumer Health Protection budget that should be addressed with the LCB staff to determine continued need.

HR, Health Facilities Hospital Licensing – Budget Page HEALTH-26 (Volume 2)

Budget Account 101-3216

Senator Rawson stated the following:

We think that there is a problem in this budget. That it is not really a balanced budget. I think rather than hassling through all the details here again, let’s have staff work on this. Essentially, we have to know if we are going to raise fees, I don’t think that was recommended. I think the state health department has to do that. Or it is their obligation. We approve it, essentially, through the budget and so we better know what we are going to do to make sure this is balanced.

HR, Community Health Services – Budget Page HEALTH-30 (Volume 2)

Budget Account 101-3224

Senator Rawson questioned whether the Community Health Services budget is receiving funds from Temporary Assistance for Needy Families (TANF) and whether the program qualifies to receive those funds. Ms. Sylva responded they are qualified to receive TANF funds for adolescent health services.

Senator Rawson asked Ms. Sylva to explain the current status of county participation fees from Carson City. Ms. Sylva responded:

Carson City has, in fact, transferred nursing positions to the Community Health Services budget in lieu of providing a portion, if you will, of public health services themselves. . . They did transfer positions in, and associated operating costs, during this current biennium and therefore the community health nursing services that are provided out of the Carson clinic are provided by state full-time staff rather than county.

Senator Rawson asked whether the counties have been advised of the need for funding. Ms. Sylva replied that they had.

Senator Rawson questioned why the county participation fees reflected in the budget show a decrease of approximately $100,000.

Philip Weyrick, Administrative Services Officer III, Fiscal, Services and Personnel, Health Division, Department of Human Resources, explained:

Due to the way the budget is developed, you know, we have to back out one-time expenditures and so forth. Sometimes we get in a situation where the actual budgeted number is lower than what was in the base year. We will, in fact, be able to work program that back up as the county fees develop during the course of the biennium. Many times we have to do one or two work programs a year for these various federal and fee-funded budget accounts.

Senator Rawson asked whether it would be preferable to address county fees now rather than during the interim. Mr. Weyrick said he would work with LCB staff to provide more accurate projections at this time.

Mrs. Cegavske asked whether any community health nurses are employed in lieu of school nurses.

Ms. Sylva responded that three counties use community health nurses in lieu of school nurses. These community health nurses provide limited hours of services, she added. She explained the community health nurse provides 8 hours of service each month in Lincoln County, 15 hours in Pahrump and Tonopah, and 4 hours in Eureka County.

Mrs. Cegavske asked whether Ms. Sylva thought A.B. 1 would affect any of their services. Ms. Sylva replied she did not believe it would.

ASSEMBLY BILL 1: Revises provisions regarding school nurses. (BDR 34-135)

Ms. Giunchigliani stated she thinks Pahrump is large enough to support a school nurse in lieu of utilizing a community health nurse. She suggested it might be preferable to provide community health nursing services to an area, which has fewer resources than Pahrump has. Ms. Sylva responded that Pahrump pays for the 14 hours a month of community health nursing services they receive.

Ms. Giunchigliani suggested the Bureau of Community Health Services should have an enforceable payment agreement with participating counties and that agreement should ensure accountability, rather than relying on “good faith,” as previously indicated.

Ms. Sylva said she would not deem the agreements enforceable. She added that the counties support their services “in cash and in kind, equivalent of about $1.5 million a year.” She said Storey County buys community health nursing services each month, so Storey County is the only county not reflected in the participation fees.

HR, Sexually Transmitted Disease Control – Budget Page HEALTH-42 (Volume 2)

Budget Account 101-3215

Senator Rawson requested performance indicators that would measure the effectiveness of the protease inhibitor program in the Sexually Transmitted Disease Control budget account. He also pointed out a vacant position within this budget.

HR, Immunization Program – Budget Page HEALTH-46 (Volume 2)

Budget Account 101-3213

Senator Rawson said a “two-tier” system resulted within the Immunization Program from federal funds supporting the Prevnar vaccine only for low-income children. He said he believes this is a policy issue that must be addressed.

Ms. Sylva explained that the Immunization Program purchases all vaccines for all children with two exceptions that were recently added: Hepatitis A and Prevnar, a pneumococcyl vaccine. Currently, it costs the state $214 to fully immunize one child, she added. She explained that the Prevnar vaccine is expensive at $46 per dose, and there are four required doses. She pointed out that to provide universal vaccinations to all children by adding Prevnar and the Hepatitis A vaccine would result in additional statewide costs of approximately $3.5 million each year.

Senator Rawson suggested a cost-benefit analysis be performed and clarified he does not equate lives with dollars. He further questioned whether these two vaccines address a significant public health issue. He requested additional information to determine the urgency of this public health issue. He indicated that if the vaccine issue is determined to be less urgent than other current issues, it might be addressed at a later time.

Ms. Leslie asked Ms. Sylva how the agency planned to improve its immunization rate of two-year-old children from the current rate of 73.4 percent, to the national immunization goal of 90 percent by the year 2000.

Ms. Sylva stated the rate is currently at 78 percent, which places Nevada thirty-fourth in the nation. She believes this ranking is misleading, as there are a large number of states grouped closely within a miniscule range. Currently, there is an immunization action plan in place, and both Washoe and Clark Counties have immunization coalitions, she added.

Ms. Leslie questioned when Ms. Sylva thought the national goals could be achieved. Ms. Sylva said it would not be in this biennium because progress is slowed as the rate approaches the goal. She explained it was easier to improve from 42 percent to 78 percent than it will be to improve from 78 percent to 90 percent. Ms. Leslie commended Ms. Sylva because Nevada has performed better in national immunization statistics than it has in most other national childhood statistics.

Ms. Leslie asked whether the Immunization Registry approved by the 1997 Legislature is working well. Ms. Silva replied that data input had been delayed because of the software vendor having declared bankruptcy. The agency is working diligently on the registry and has now included more than 160,000 entries. Two HMOs in southern Nevada will soon be brought online enabling them to input their data directly into the Immunization Registry, she added. The registry will be effective in tracking children who require subsequent immunizations. Ms. Silva said she believes this would increase the total number of fully immunized children.

Ms. Leslie questioned whether the rural areas have access to the Immunization Registry. Ms. Sylva replied that the rural areas do have access to and actively use the registry.

Senator Rawson asked Ms. Sylva to explain the problem with the registry in greater detail. Ms. Sylva said the division was forced to start the data input process over when a new software vendor stepped into place, but this should not happen again.

Senator Rawson asked whether the registry tracks reactions or merely immunizations received. Ms. Sylva said she does not know whether reactions are included in the registry, but she assured Senator Rawson she would find out for him. Senator Rawson noted he believes there is a low incidence of reactions, and Ms. Sylva agreed.

Janine Hansen, Lobbyist, State President, Nevada Eagle Forum, asserted there are issues overlooked in the Immunization Program budget. She provided a handout with various documents (Exhibit J. Original is on file in the Research Library.), including information from the National Vaccine Information Center. The first section of Exhibit J is dedicated to relating the stories of two children who were permanently disabled from vaccinations and two other infants who died from vaccinations. Ms. Hansen said she became interested in vaccine safety when her daughter suffered a severe reaction to a vaccination. She informed the committee her daughter’s reaction entailed a seizure, 105-degree temperature, and cessation of breathing, but she recovered fully from the reaction. Ms. Hansen later read that children who have suffered a febrile seizure should not receive the diptheria, tetanus and polio (DTP) vaccination. However, she said, the Washoe County Health Department refused to excuse her daughter despite a doctor’s written recommendation.

Ms. Hansen referred to a statement prepared by Barbara Loe Fisher, Co-founder and President, National Vaccine Information Center for the Institute of Medicine Immunization Safety Committee, National Academy of Sciences, Washington, D.C. (Exhibit J). The written statement addresses potential links between widespread vaccinations and dramatic increases in the incidence rates of asthma, attention deficit disorder, diabetes, learning disabilities, and autism.

Ms. Hansen referred to the pink document within Exhibit J, distributed by the Center for Disease Control (CDC), which addresses the Vaccine Adverse Event Reporting System (VAERS). She stated Congress implemented an adverse reaction reporting system in the 1980s, but the CDC believes only about 10 percent of all reactions are reported. She further addressed numerous reported vaccine reactions described in the green section of Exhibit J. She provided a glossary of medical terms and a second statement included in Exhibit J, prepared by Barbara Loe Fisher, addressing compensation of vaccine injuries. Ms. Hansen stated the National Childhood Vaccine Injury Act of 1986 created the Vaccine Injury Compensation Program, but the program has become “adversarial.” Only one-fourth of child applicants to this program receive any consideration, she added. Parents who submit their children to mandated vaccinations and whose children subsequently suffer detrimental health and economic problems have been denied any redress.

Many vaccinations contain thimerosal (mercury) that results in babies’ potentially receiving 40 times the amount of mercury deemed safe under the Environmental Protection Agency (EPA) guidelines (Exhibit J), Ms. Hansen stated. According to Ms. Hansen, Congress directed the Food and Drug Administration to recall all thimerosal-containing vaccines, but the FDA has not complied, despite acknowledgement that all the vaccines are available in a thimerosal-free version, she added.

Ms. Hansen suggested there should be an effort to identify and record vaccine reactions in Nevada and to provide support to families suffering economically, in addition to the physical effects, from a vaccine injury. Many parents do not realize their children’s problems stem from a vaccination and those counts have, therefore, not been included in existing statistics, she added.

Lynn Chapman, Lobbyist, Nevada Eagle Forum, speaking as a private citizen, said that years ago she had a reaction to a tetanus immunization, and that her daughter suffered a reaction to the MMR (measles, mumps, and rubella) vaccination. Nine days after receiving the vaccination her daughter began having grand mal seizures, so she was prescribed Phenobarbital, a sedative. She said her daughter suffered no long-term effects and has been weaned from Phenobarbital. This experience caused Ms. Chapman to decline all subsequent vaccinations for her daughter, she said, and her daughter avoids school district admission guidelines for immunizations because she is home-schooled. Ms. Chapman requested financial assistance for families who suffer the economic consequences of a vaccine-related injury.

Senator Rawson suggested Ms. Chapman discuss with a doctor her daughter’s known allergy to the vaccine and the potential risks of not having her daughter immunized. He pointed out there may be a safer solution.

Senator Rawson asked Ms. Sylva whether vaccine-injured children have access to assistance through any known programs in Nevada.

Ms. Sylva said she is unfamiliar with eligibility requirements for the following programs but they could be potential sources of assistance: Medicaid, Supplemental Security Income (SSI), Child Health Assurance Program (CHAP), or Kati Beckett Program. She stated it is her agency’s policy to refer children who suffer adverse reactions to the national program for funding assistance. Any child, who meets the requirements for Special Children’s Clinics, would be treated at the clinics without hesitation, she added. Another option is the Children with Special Health Care Needs program, which pays the medical costs for eligible children.

Senator Rawson suggested legislative intent should indicate it is of public concern to assist “vaccine-injured” children regardless of their income level. He added that Ms. Sylva should identify specific programs and the assistance they could offer these special cases. He asked Ms. Sylva to work with LCB staff on projecting costs to provide the eligible programs to these few special cases.

Mrs. Cegavske asked Ms. Hansen whether parents are provided a written statement explaining vaccination risks and whether they are required to sign a waiver of legal rights prior to the vaccination. Mrs. Cegavske further asked Ms. Sylva whether any lawsuits have resulted from this issue.

Ms. Hansen said the National Compensation Act was implemented in the 1980s in response to many lawsuits over this issue. She stated the National Compensation Act has become adversarial and bureaucratic, providing very little assistance. She further stated parents’ opportunity to sue is compromised by this ineffective legislation. She said she believes written statements explaining vaccination risks are provided, but she was uncertain whether the statements include any type of waiver of legal rights. She stated the opportunity to sue has been forfeited at the national level when Congress implemented the National Compensation Act, which is not effective.

Ms. Sylva stated all parents or legal guardians are provided with information regarding the purpose of the vaccine prior to the vaccination. She said she is uncertain whether there is a disclaimer clause on the informed-consent sheet or informational handout the parents receive. All parents sign an informed-consent sheet prior to the immunization, she added. Public health entities and private physician offices provide these services. She added that one universal package of information is provided statewide, but private physicians may provide additional information.

Mrs. Cegavske asked Ms. Sylva to provide the joint subcommittee a copy of these information packages. The statistics on children who suffer adverse reactions to immunizations appears understated, she commented.

Ms. Hansen responded that the Center for Disease Control suggests that only 10 percent of adverse reactions are reported.

Mrs. Cegavske questioned how parents could determine whether their child’s symptoms are associated with immunizations. She suggested it is a complicated issue because the immunizations prevent widespread diseases, but for some children immunization has negative results.

Ms. Hansen agreed that immunization is a complicated issue, and it becomes even more complicated for those people whose children are vaccine-injured.

Ms. Giunchigliani asked Ms. Sylva whether the state pays for immunizations received through private physicians in addition to those administered through public health. Ms. Sylva said private physicians administer all vaccines, including Prevnar and the Hepatitis A vaccine, to the children eligible for the Vaccines for Children program; the vaccine is provided to them at no cost. When private physicians administer vaccines to children who are not eligible for the Vaccines for Children Program, they receive all vaccines except Prevnar and the Hepatitis A vaccine at no cost.

Ms. Giunchigliani asked whether eligibility for the Vaccines for Children Program was an income standard, and whether the excluded children could receive the Prevnar and the Hepatitis A vaccines through their private insurance. Ms. Sylva responded in the affirmative in both instances.

Ms. Giunchigliani asked whether immunizations were only required of children attending schools. Ms. Sylva said proof of immunization is required at the “point of entry” into the schools whether this be at the beginning of their education or upon return to the system. Ms. Giunchigliani asked whether any studies have addressed the risk factors to the rest of the community caused by people who have not been immunized. Ms. Sylva said many studies exist which address “herd immunity” regarding large groups of people who are not immunized in an immunized society.

Senator Rawson added that outbreaks of measles have resulted from this situation. Ms. Giunchigliani added that the increase in tuberculosis incidences might also be a result of this. The immunization program has been beneficial to the public for the most part, she stated.

HR, Maternal Child Health Services – Budget Page HEALTH-51 (Volume 2)

Budget Account 101-3222

Senator Rawson stated that during the 1999 Legislative Session $441,574 in Maternal and Child Health Block Grant funds were directed toward a statewide dental health initiative, but $189,000 of that authorization remains unspent. He said this was a one-time authorization that apparently was difficult to distribute. However, he pointed out, many groups who require care still exist. He cited “baby bottle syndrome” as a persistent issue. He said he hoped Ms. Sylva could offer insight into utilizing similar funds in the future.

Ms. Sylva said the remaining balance of funds is actually $117,000. She cited success in a curriculum established jointly by the Health Division and Head Start to focus on early childhood caries. This program was initiated in Las Vegas, but has now become a national Head Start program because of its continued success, she noted. The Health Division learned a great deal from the dental health initiative and gained many valuable partners related to the introduction of fluoride varnish. Programs in northern Nevada benefited through the Take Care A Van, and the number of children with sealants was substantially increased. Ms. Sylva explained many of the programs initiated slowly, and she requested an additional year to utilize the remaining funds.

Senator Rawson said it does not appear as a reversion in the budget. Ms. Sylva explained they did not anticipate remaining funds when they submitted the budget. He stated he would support their continued use of the funds, but he anticipated other groups might be interested in those funds.

Senator Rawson suggested there were similarities between the National Health Service Corps Student Experiences and Rotations in Community Health Program (SEARCH) and the Health Care Access Program (HCAP) administered by the Western Interstate Commission for Higher Education (WICHE). He recommended that Maternal Child Health Services discuss with WICHE methods to enhance both their programs through joint efforts. The SEARCH grant included $145,000, he added.

Senator Rawson stated that Senator Wiener had expressed concern over the advisory subcommittee on fetal alcohol syndrome, which received $25,000 during the 1999 Legislative Session, and spent only $226 in FY 2000. Mr. Weyrick replied that the unused funds had been inadvertently reverted. To re-establish that authority in the current fiscal year, work programs were recently submitted. He said the division anticipated spending all the funds by June 2001.

Ms. Giunchigliani asked whether the funds were for the advisory committee or for the provision of services. She objected to use of the funds solely for the advisory committee.

Ms. Sylva said the intent of the $25,000 was for a committee to study prevention activities throughout the nation for possible implementation in Nevada.

Ms. Giunchigliani said she believes that information could be accessed without the use of a committee simply through technological access. She questioned what the $226 had been used for. Mr. Weyrick responded it had been spent for supplies to initiate the program, such as informational flyers.

Ms. Giunchigliani acknowledged a need for services in this area exists, but she questioned whether the state is the appropriate provider.

Senator Rawson informed the committee Senator Wiener would like to participate in discussion on this budget before it is closed.

HR, Emergency Medical Services – Budget Page HEALTH-66 (Volume 2)

Budget Account 101-3235

Senator Rawson said despite a critical need for training rural Emergency Medical Technicians (EMTs), only $3,854 out of the $12,855 collected in fees was used for training. The remaining balance, $9,001 was carried forward into fiscal year 2000-2001. He asked Ms. Sylva to suggest how the training program could become more actively engaged. He further noted that other funds appropriated to the Emergency Medical Services (EMS) budget account had not been fully utilized.

Ms. Sylva responded that the 1999 Legislature approved an Emergency Medical Services Rural Initiative program, which appropriated $20,000 each year throughout the 1999-2001 biennium. She explained the purpose was to provide training and testing to EMS personnel through the purchase of a trailer and dummy for use throughout Nevada. The training equipment was not purchased until late in the year, and the program proceeded slowly, she added. According to Ms. Sylva, a $7,500 reversion resulted from not utilizing all available funds, but it has since been restored. She acknowledged a training need in the rural areas and explained a training schedule is being prepared to more effectively utilize all available funds.

Senator Rawson asked how active the EMS Committee is. Ms. Sylva said the EMS Committee met four times during the 1999-2001 biennium; they reviewed training curriculum and entertained guest speakers on the 800-megahertz system. The 800-megahertz system has been consistently discussed with little progress during her tenure with the Health Division, she added. Senator Rawson commented that the Nevada Highway Patrol Division and the police had progressed with this system, so progress may be imminent for the EMS. An EMS Committee meeting is scheduled in early March to better define the objectives of the committee, Ms. Sylva stated.

HR, Health, Alcohol & Drug Rehabilitation – Budget Page HEALTH-70 (Volume 2)

Budget Account 101-3170

Ms. Sylva discussed the transfer of the Bureau of Alcohol and Drug Abuse (BADA) program from the Department of Employment, Training and Rehabilitation to the Health Division, which occurred July 1, 1999. Prior to that date BADA endured 5 different Bureau Chiefs during a 4-year time span, and the Bureau Chief resigned the day before the transfer took place, essentially creating a leadership void, she explained. The remaining BADA staff had not been actively involved in any policy decisions, so this further complicated the transition. Ms. Sylva requested an audit of BADA by the LCB Audit Division on July 1, 1999, and three additional audits were subsequently conducted during the past 1-½ years. Complying with the requirements from the 1999 Legislative Session, combined with the repeated audit process, was extremely time consuming for BADA, she stated.

Ms. Sylva informed the committee that BADA has 27.5 employees, and has experienced a 66 percent turnover rate. A loss of “institutional memory” occurred with the departure of the employees, she added. The 1999 Legislature authorized $500,000 of the revenue generated in each year of the 1999-2001 biennium for the Department of Human Resources through its contract with MAXIMUS to be used to implement substance abuse treatment programs for adolescents as outlined in A.B. 181 from the 1999 Legislative Session.

ASSEMBLY BILL 181 OF THE SEVENTIETH SESSION: Makes various changes relating to provision of services relating to substance abuse and mental health. (BDR 40-1059)

Ms. Sylva referred to the budget account 101-3170 information located in Exhibit C, which provides many answers to questions, received at the hearing on January 24, 2001, in particular those asked by Ms. Leslie. She said she believes MAXIMUS revenue enables the bureau to serve about 58 percent of the adolescents in Nevada who need substance and alcohol abuse treatment.

Ms. Sylva said the agency allocated $158,400 to three pilot projects provided through the family resource centers. She noted those funds were approved and monitored by the drug commission of the Department of Motor Vehicles and Public Safety. She said she believes the drug commission and BADA overlap in many of the services provided. BADA and the Department of Motor Vehicles and Public Safety agreed, during the 1999 Legislative Session, that BADA would fund a Program Officer position within the drug commission. BADA proposes to discontinue funding of this Program Officer position within the drug commission as it provides similar services to those provided by BADA.

Ms. Sylva stated that S.B. 210 of the 1999 Legislative Session removed the responsibility for certification of drug and alcohol counselors from BADA. Ms. Sylva explained that a separate certification board was created for this purpose, effective July 1, 2000.

SENATE BILL 210 OF THE SEVENTIETH SESSION: Provides for regulation of persons who counsel alcohol and drug abusers. (BDR 54-163)

Ms. Sylva described additional legislation passed during the 1999 Legislative Session. S.B. 161 required BADA to promulgate regulations to approve “half-way houses.” Those regulations have been filed with the Office of the Secretary of State, and are currently in effect.

SENATE BILL 161 OF THE SEVENTIETH SESSION: Provides for regulation of all facilities for treatment of abuse of alcohol or drugs. (BDR 40-131)

Ms. Sylva further explained that the 1999 Legislative Session approved a set-aside of $280,000 Substance Abuse, Prevention and Treatment (SAPT) Block Grant funds for the Juvenile Justice, Truancy and Drop-out Reduction prevention programs. She said those funds have been allocated to nine judicial districts to reduce truancy and school drop-out rates. BADA will be working closely with the nine judicial districts to establish performance indicators to measure the effectiveness of these funds, she noted.

She stated it is crucial that Nevada remain in compliance with the Synar Amendment, which requires that less than 23 percent of Nevada youth are able to purchase tobacco. This program is included in the Attorney General’s office, and is funded through the Healthy Nevada Trust Fund, “the Tobacco Trust Fund.” If Nevada exceeds a 23 percent “youth buy rate,” the state would lose nearly 40 percent of its SAPT Block Grant funds, or $3.8 million in federal funds, she explained.

Ms. Sylva said she anticipates an increase in SAPT Block Grant funds by more than $1 million annually. The agency is conducting strategic planning for the use of these additional funds, she said. These SAPT Block Grant funds, as always, will have a prescribed allocation among programs for prevention of alcohol and drug abuse, and specific high-risk populations such as pregnant women, people with HIV or AIDS, or people with tuberculosis.

Ms. Sylva said that pursuant to a prior request from Senator Raggio, detailed information on the 29 treatment and prevention programs funded by the Health Alcohol and Drug Rehabilitation budget is included in Exhibit C. The request for proposal (RFP) document and supporting information for the RFP process is enclosed in Exhibit C also, she added. Numerous charts and graphs detail the recipients of BADA funds (Exhibit C). She noted that 28 percent of the recipients of BADA funds are “at or below 200 percent of poverty.”

Ms. Giunchigliani asked what the rationale is to have Ms. Sylva’s division address school drop-out rates.

Ms. Sylva replied that school drop-out rates are often associated with substance abuse. Ms. Giunchigliani acknowledged that may be true, but she does not feel the nine judicial districts would be proactive in working with these youth. She suggested the Drug Court or another existing program, public or private, might be more appropriate for this work.

Senator Rawson acknowledged that employee turnover impeded implementation of meaningful performance indicators for this budget account. In light of the funds spent supporting the grants in this budget, he stated a desire to assess the amount of public good achieved by these programs. He said he hopes to avert any potential crises in these programs through further study of the performance indicators.

Ms. Leslie thanked Ms. Sylva for providing answers to previous questions from the committee. She questioned whether the statistics Ms. Sylva provided actually indicate that 40 percent of the adolescents who desire treatment are currently unable to access it, despite the MAXIMUS funding. Ms. Sylva replied that was true.

Ms. Leslie also asked Ms. Sylva to discuss the status of the three pilot projects provided through the family resource centers and funded with a one-time appropriation of $158,400 through this agency. Ms. Leslie indicated this information would assist discussion to continue those projects. Ms. Sylva responded she would provide additional information.

Ms. Leslie said she assumed the anticipated SAPT Block Grant funding increase was due to the population growth reported in the 2000 Census. She questioned how much of those new funds would be designated for prevention. Ms. Sylva said she is not certain but will provide a rough estimate to Ms. Leslie.

Ms. Leslie agreed with Ms. Giunchigliani that some of BADA’s efforts are a duplication of the drug commission. She asked whether community coalition people are included in the advisory board. Ms. Leslie further questioned whether BADA has established an advisory board similar to the existing drug commission in which law enforcement interacts with the prevention and treatment providers.

Ms. Sylva replied that law enforcement is not currently involved in the advisory board, established in December 1999. She replied they would be receptive to expanding the advisory board if the Department of Public Safety, Drug Commission is discontinued. Ms. Leslie said she believes two similar bodies are unnecessary, but all facets of the community should be involved in one.

Ms. Sylva responded to the earlier question from Ms. Leslie concerning distribution of the increase in SAPT Block Grant funds; 20 percent will be allocated to prevention.

Mrs. Cegavske disclosed that she is an employee of Westcare Foundation, and she will not benefit from this funding.

Kevin Quint, Executive Director, Join Together Northern Nevada, and Chairman, Bureau of Alcohol and Drug Abuse Advisory Committee, said the MAXIMUS funding has been critical to adolescent treatment programs.

Senator Rawson asked Ms. Sylva to work with LCB staff on projecting MAXIMUS funding in the current budget in lieu of waiting to address this during Interim Finance Committee meetings.

Mr. Quint stressed the importance of complying with the Synar Amendment to ensure continued treatment and prevention programs in Nevada. Senator Rawson asked LCB staff to keep the Synar Amendment requirements in mind when making recommendations.

HR, Special Children’s Clinic – Budget Page HEALTH-57 (Volume 2)

Budget Account 101-3208

E-125 Equitable, Stable Tax Structure – Page HEALTH-59

Mary Kathleen Cronin, speaking as a private citizen, testified from Las Vegas in opposition to the elimination of the Public Service Interns (PSIs). She said her grandson has cerebral palsy, and he currently receives group therapy at the Special Children’s Clinic. She said she has two other grandchildren on the waiting list for services. She read statements from other parents opposing the elimination of the PSIs. She said she believes additional staff should be considered, rather than reductions to staff.

Yvonne W. Isola, speaking as a private citizen, testified in opposition to the elimination of the PSIs. She said she believes Nevada reaps long-term benefits from the financial investment in the interns. Five of the current six developmental specialists are former PSIs, she read from her written testimony (Exhibit K).

HR, Health Alcohol & Drug Rehabilitation – Budget Page HEALTH-70 (Volume 2)

Budget Account 101-3170

Kari Demetras, Chief Executive Director of Step 2 and Member, Bureau of Alcohol and Drug Abuse Advisory Committee, addressed Senator Rawson’s request for performance indicators for BADA. She stated she is anxious to provide these indicators as evidence of the success of their programming.

The meeting was adjourned at 10:52 a.m.

RESPECTFULLY SUBMITTED:

Jennifer Ruedy

Committee Secretary

APPROVED BY:

Senator Raymond D. Rawson, Chairman

DATE:

APPROVED BY:

Assemblywoman Christina R. Giunchigliani

Chairman

DATE: