SENATE BILL REPORT

                                    SB 6034

             AS REPORTED BY COMMITTEE ON HEALTH & LONG-TERM CARE,

                                JANUARY 28, 1992

Brief Description:  Making major changes to health care and planning.

SPONSORS:Senator West

SENATE COMMITTEE ON HEALTH & LONG‑TERM CARE

Majority Report:  That Substitute Senate Bill No. 6034 be substituted therefor, and the substitute bill do pass. 

      Signed by Senators West, Chairman; L. Smith, Vice Chairman; Amondson, and Newhouse.

Minority Report:  That it not be substituted. 

      Signed by Senator Niemi.

Staff:  Scott Plack (786‑7409)

Hearing Dates:January 14, 1992; January 28, 1992

SENATE COMMITTEE ON WAYS & MEANS

Staff:  Cindi Holmstrom (786-7715)

Hearing Dates:February 4, 1992

BACKGROUND:

Many major improvements in the health of the American people have been accomplished through public health measures (population-based health care services).  Control of epidemic diseases, safe food and water and maternal and child health services are only a few of the public health achievements that have prevented countless deaths and improved the quality of American life.  However, there is a growing concern that no clear consensus exists on the goals of the current and future public health system and that this lack of consensus is driving the system into disarray.  At the same time, the public health system is expected to continue to address many health threats and crises such as the AIDS epidemic.  Furthermore, state funding to support basic local public health functions has been very limited.

There has been an increase in the number of young children contracting infectious diseases.  This trend occurs despite the availability of safe and effective immunizations against such diseases.  Current law requires that children entering private or public schools or licensed day care centers provide proof of immunizations or a waiver signed by the parent or child's physician.

The leading causes of death in Washington include accidents, cancer, heart disease, cirrhosis, homicide and suicide.  These are often the result of individuals engaging in high risk behavior regarding their lifestyle.  Health promotion and disease prevention efforts can help reduce their occurrence.  The U.S. Public Health Service has recommended health promotion and disease prevention national objectives that provide specific targets for such reductions.  The state Department of Health (DOH) currently lacks specific authority to establish health promotion strategies or to address risk factor behavior modification activities.

Community health outreach programs using lay members to identify and refer to services at-risk pregnant/parenting women and isolated elderly living at home are receiving considerable attention.  Such programs have demonstrated improvements in health outcomes among targeted high-risk populations.  Current outreach efforts are primarily focused on multi-media campaigns and telephone hotlines and have not addressed access barriers for individuals without family support networks.

Currently, there are no state funds specifically set aside to provide health services to children in schools.  Many school districts do not have adequate health personnel providing health services to school children.  The availability of these services can reduce sickness and enhance learning experiences for these children.

Inadequate numbers of health care personnel in rural and medically underserved areas of the state is well acknowledged.  The state's loan repayment and scholarship program is viewed as an effective recruitment device, but funding is currently limited.  In addition, providing rural training opportunities for medical students is seen as an effective means of attracting doctors to these areas, but such programs have also been limited by funding.

Community and migrant clinics provide essential primary care for thousands of low-income citizens in the state.  They are viewed as a very cost-effective means for providing primary care services.  While demand for these services is increasing, current public funding to the clinics is limited.

The state's Basic Health Plan is a low-income insurance plan administered and subsidized by the state.  Individuals with incomes between 100 percent and 200 percent of poverty may apply and receive health insurance with health care services provided in managed health care settings.  The program is currently limited to 24,000 people, but the plan can accommodate a significant number of new enrollees.

The Women, Infants and Children's (WIC) supplement food program has been demonstrated to effectively improve the physical and mental health of participants, increase the number of women seeking prenatal care and reduces infant mortality.  Current program funding limits participation to about 50 percent of those eligible.

SUMMARY:

The Good Health Care Account is created in the state treasury.  An appropriation of about $131 million is made from the state general fund to the account.  Separate appropriations are made from the account to fund activities established in the bill.  These include funding for population-based health care services, childhood immunizations, regional health promotion efforts, community health outreach efforts, health services for school children, and outreach efforts for at-risk elderly citizens.

In addition, funding is provided for existing programs and activities.  These include funding for the expansion of the University of Washington family medicine residency program, additional awards for the state's health professional loan repayment and scholarship program, expanded primary care services for 30,000 people at the state's community and migrant health clinics, increased enrollments in the state's Basic Health Plan for about 34,000 people, supplemental funding for the state cancer registry, a 10 percent increase in the number of eligible people in the WIC program, and grants to nonprofit organizations conducting education programs on cancer and other smoking-related disease.

DOH in consultation with other agencies, local health jurisdictions and the state Board of Health is directed to establish a statewide population-based health care system.  DOH is required to prepare a statewide population-based health services plan by October 1, 1991 that identifies core services and functions necessary to assure the presence of a statewide population-based system.  This includes an ongoing capability to assess health status and health-related conditions, to develop public policy objectives, to identify essential population-based health care needs and to provide services to address the identified needs.  The plan will identify activities necessary to assure the provision of services related to health promotion, community health protection, and personal disease prevention.

The local health jurisdictions are required to establish a local population-based health care system.  The local jurisdictions are also required to prepare local population-based health services plans by June 1, 1993.  These laws must include the functions and services capabilities required to meet local needs and must be approved by DOH.  Specific criteria for approval are identified.  DOH is required to determine a distribution formula for the funding appropriated by the act.  Local jurisdictions may combine to jointly provide population-based health services upon approval of the department.  DOH may create local plans and provide services and functions for those public health jurisdictions unable or unwilling to do so.

The completion date for the state health report is changed to make it due in advance of development of the state biennial budget and to coordinate it with the development of population-based health care system objectives at the state and local level.

The state Board of Health is directed to adopt rules establishing a schedule of appropriate immunizations against infectious diseases for adults and children.  Beginning in January 1993, the Secretary of Health, in consultation with DSHS, is directed to establish five demonstration projects for the purpose of determining the best method to increase immunization rates among children who receive state paid services.  Beginning in January 1995, all children receiving state paid services from DOH, DSHS, the Basic Health Plan, and the Health Care Authority are required to receive appropriate immunizations or present waivers indicating medical reasons for noncompliance or personal or religious objections to the immunizations.

Each local health jurisdiction is required to submit in its local population-based health services plan a description of local activities to increase immunization rates among at-risk populations.  Children attending licensed day care homes are required to meet appropriate immunization schedules or provide waivers.

The Center of Health promotion is established within DOH.  The center will contain departmental functions related to the promotion of health and prevention of disease and injury.  As part of the statewide population-based health services plan, the center shall assist DOH to identify leading causes of death, risk factors associated with these illnesses, descriptions of at-risk populations, and strategies to reduce illness and injury.  The center shall establish biennial statewide health promotion and disease prevention objectives.  National objectives are cited and serve as minimum objectives for the state.  The center shall also serve as a clearinghouse for public and private groups desiring to implement strategies to reduce illness and injury.

Health promotion and disease prevention regions are to be established by DOH by October 1, 1992.  Each region shall prepare regional health promotion and disease prevention strategies to be incorporated into the local population-based health services plans.  The proposals shall include interventions, such as health services screenings and public education campaigns that have demonstrated effectiveness in promoting health and reducing injury.  Intervention strategies targeted at children and adolescents are to be coordinated with local school districts.  Multi-local health jurisdictional proposals are authorized.  The state Board of Health shall review health promotion and disease and injury prevention objectives as part of the state health report.

The Secretary of Health is directed to assist local health jurisdictions to establish ten pilot community outreach for health programs.  Local health jurisdictions are to identify in their population-based health services plans geographic areas and target populations experiencing substantial health risks among pregnant and parenting women and are to develop outreach health programs for such women.  Outreach programs are to use community volunteers and shall focus on education, referral and other activities facilitating access to public and private community resources.  A 50 percent local funding match is required to receive funds appropriated in the act.

Each local health jurisdiction may assess as part of the population-based health services plan the health service needs of children in grades K-8 in public and private schools.  Local health jurisdictions may enter into interlocal agreements with school districts to provide health services to these children.  Funds appropriated by this act are to be distributed on a per-capita basis.  DOH is required to report to the Legislature by December 1993 on the rate of participation and progress of the program as well as recommendations for its improvement.

DSHS is directed to assist the Area Agencies on Aging (AAAs) to establish gatekeeper programs.  Gatekeepers are defined as individuals who, as a part of their job, have contact with the isolated elderly living in the community.  Such persons include postal carriers, EMS technicians and public utility personnel.  The AAAs are directed to contract with existing community organizations to recruit and train gatekeepers who will help identify at-risk isolated elderly living alone in private homes and to develop a plan to refer these individuals to appropriate public and private personal care services.  The program shall be funded through grants which require a 50 percent match by the local community.

EFFECT OF PROPOSED SUBSTITUTE:

The following changes were made.

The University of Washington is directed to expend the medical residency appropriation to only train physicians in family practice who provide medical care to those in rural and medically underserved areas.  They are also directed to use the appropriation in a manner to maximize possible federal and nonstate matching moneys.

The number of people who are eligible for the basic health plan expansion from 34,000 to 40,000.  State and local health jurisdictions are to solicit the active participation of interested parties in the development of population based health services policy development.

The facilities, property, services, activities, employees, volunteers, or funds used by or in conjunction with the bill shall not be used for abortion services, referrals or information.  This prohibition shall not be denied, interfered with, or discriminated against under any current law or any law enacted hereafter unless specifically repealed or amended by reference to its RCW section.

The requirements that children receive appropriate immunizations or provide signed waivers is limited to children under five years of age.  School health services are to be provided to children in private as well as public schools.  These services will be available for children in grades K-12 instead of just through the eighth grade.  A null and void clause is added to the bill.

Appropriation:  $130,761,850 from state general fund

Revenue:  none

Fiscal Note:  requested January 10, 1992

Effective Date:  The bill contains an emergency clause and takes effect immediately.

TESTIMONY FOR:

The bill addresses a wide range of public health, disease prevention, and health promotion needs in the state.  It also provides statutory authority and direction for public health activities at the state and local level.  Specific funding for health professional loan repayments, medical residency training and community health clinics will help assure primary care health services for people in rural and medically underserved areas of the state.

The basic health plan appropriation will permit an additional 40,000 low-income working people to have subsidized health insurance.  The immunization provisions will help increase immunizations rates among young children where immunization compliance rates are below 50 percent.  Health services for school-aged children will help schools and county health departments provide needed preventative health care services to school-aged children.  Community outreach programs for pregnant women and the elderly will help identify and refer these people to available health and social services.

TESTIMONY AGAINST:

The bill is vaguely written and funding may be used to provide abortion related services.

TESTIFIED:  Lisa Hoffmann, State Board of Health; Tim Smolen, WSPHA; Leah Layne WACHC & WRHA (pro); Sherrie Ostby, Headstart parent (pro); Karen Holt, RN, Thurston County Health (pro); Gladys Burns, Child Abuse Prevention Assn. (pro); Florence Reeves, Community Health Care Clinic; Dorothy Peterson, Community Care Program; Nancy Foote, Yakima Valley Farmworkers Clinic; Mary Jokahler, Human Life of WA (con); Mike Ryherd, Fred Hutchinson Cancer Research Center (pro); Margaret Casey WA State Catholic Conference (pro); G. Tyler, senior citizen (pro); Ron Schneeweiss, MD (pro); Philip Cleveland, MD (pro); Bob Atwood, MD, Yakima Health District (pro); Larry Jecha, MD, Benton/Franklin Health District (pro); D. Harvey McIntyre, Washington Federation of Independent Schools (pro); Ray Day, Tacoma Pierce County Health Dept. (pro); Dr. Bruce Davis, Group Health Cooperative (pro); Sue Hutchins, Washington Assoc. of Local WIC Agencies (pro); Donna Oberg, WALWICA (pro); Evan A. Iverson, Senior Lobby (pro); Keith Frey, MD (pro); Lis Gildemeister, Charla Dunham, Anne Ozmun, Washington State Nurses Assn. (pro); Elsie Chayet, Seattle/King County Health Dept.; Mimi Fields, Carole Washburn, Elizabeth Ward, Dept. of Health