S-3154

AN ACT Relating to health care; amending RCW 43.70.050, 28A.210.070, 43.59.030, and 74.38.020; reenacting and amending RCW 43.20.050; adding new sections to chapter 43.70 RCW; adding new sections to chapter 43.20 RCW; adding a new section to chapter 43.20A RCW; adding a new section to chapter 70.47 RCW; adding a new section to chapter 41.05 RCW; adding new sections to chapter 74.38 RCW; creating a new section; making appropriations; and declaring an emergency.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

TABLE OF CONTENTS

PART Page #

PART I - APPROPRIATIONS........................................................ 3

PART II - POPULATION-BASED HEALTH CARE SERVICES................................ 7

PART III - CHILDHOOD IMMUNIZATIONS............................................. 20

PART IV - REGIONAL HEALTH PROMOTION............................................ 29

PART V - COMMUNITY OUTREACH FOR HEALTH......................................... 36

PART VI - HEALTH SERVICES FOR SCHOOL CHILDREN.................................. 38

PART VII - GATEKEEPER OUTREACH PROGRAM......................................... 39

PART VIII - MISCELLANEOUS...................................................... 42

PART I - APPROPRIATIONS

NEW SECTION. Sec. 1. GOOD HEALTH CARE ACCOUNT ESTABLISHED. The good health care account is created in the state treasury. Moneys in the account may be spent only after appropriation. Expenditures from the account may be used only for the purposes of this act and for other disease prevention, health education, and health care intervention services for high-risk individuals.

NEW SECTION. Sec. 2. GENERAL FUND--STATE APPROPRIATION. The sum of one hundred thirty million seven hundred sixty-one thousand eight hundred fifty dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the state general fund to the good health care account for the purposes of this act.

NEW SECTION. Sec. 3. POPULATION-BASED HEALTH SERVICES FUNDING. The sum of forty-four million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for distribution to local health departments for the purposes of funding population-based health services as authorized in sections 16 through 21 of this act. The funding is to be dispersed by the department in accordance with the formula set forth in section 19 of this act.

NEW SECTION. Sec. 4. IMMUNIZATION FUNDING. The sum of one million three hundred thousand, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the childhood immunization activities authorized in sections 23 through 29 of this act. Portions of this appropriation not expended shall be distributed as per section 19 of this act to local health jurisdictions for the purposes of funding population-based health services authorized in sections 16 through 19 of this act.

NEW SECTION. Sec. 5. REGIONAL HEALTH PROMOTION FUNDING. The sum of one million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the regional health promotion activities authorized under sections 31 through 34 of this act. Portions of this appropriation not expended shall be distributed as per section 19 of this act to local health jurisdictions for the purposes of funding population-based health services authorized in sections 16 through 19 of this act.

NEW SECTION. Sec. 6. COMMUNITY OUTREACH FOR HEALTH FUNDING. The sum of four hundred thirty thousand dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the community outreach for health activities authorized under sections 36 and 37 of this act. Portions of this appropriation not expended shall be distributed as per section 19 of this act to local health jurisdictions for the purposes of funding population-based health services authorized in sections 16 through 19 of this act.

NEW SECTION. Sec. 7. SCHOOL HEALTH SERVICES FUNDING. The sum of twenty million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the school health services activities as authorized in sections 38 and 39 of this act. Funds shall be provided to reimburse public health jurisdictions for an amount not to exceed the number of dollars appropriated per eligible student multiplied by the number of eligible students to be served by the jurisdiction in the participating school district. The public health departments shall spend the moneys as limited under section 39 of this act.

NEW SECTION. Sec. 8. GATEKEEPER OUTREACH PROGRAM FUNDING. The sum of three hundred fifty thousand dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of social and health services for the purposes of funding the gatekeeper outreach program authorized in sections 40 through 42 of this act.

NEW SECTION. Sec. 9. FAMILY MEDICAL RESIDENCY FUNDING. The sum of one million eighty-one thousand eight hundred fifteen dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the University of Washington for the purposes of funding the state-wide family medicine residency program authorized under chapter 70.112 RCW. The conditions set forth in RCW 70.112.060 regarding expenditures of state funding shall apply to this appropriation. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 10. HEALTH PROFESSIONAL LOAN REPAYMENT AND SCHOLARSHIP PROGRAM FUNDING. The sum of five million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the health professional loan repayment and scholarship program fund to be dispersed by the higher education coordinating board for the purposes of funding the health professional loan repayment and scholarship program authorized under chapter 28B.115 RCW. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 11. COMMUNITY AND MIGRANT HEALTH CLINICS FUNDING. The sum of two million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the expansion of primary health care services to new clients through community and migrant health clinics. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 12. BASIC HEALTH PLAN FUNDING. The sum of forty-five million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the Washington basic health plan authorized under chapter 70.47 RCW for the purposes of enrolling no more than thirty-four thousand additional members during the 1991-1993 biennium. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 13. CANCER REGISTRY FUNDING. The sum of five hundred thousand dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the cancer registry as authorized under RCW 70.54.230 and 70.54.240. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 14. WIC FUNDING. The sum of ten million dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of funding the women, infants and children program. This amount is in addition to that set forth in the 1991-1993 biennial appropriations act.

NEW SECTION. Sec. 15. GRANTS TO NONPROFIT ORGANIZATIONS WITH CANCER AND OTHER DISEASE EDUCATION PROGRAMS. The sum of one hundred thousand dollars, or as much thereof as may be necessary, is appropriated for the biennium ending June 30, 1993, from the good health care account to the department of health for the purposes of awarding grants to national organizations with Washington state chapters that address issues of disease and illness related to smoking tobacco.

PART II - POPULATION-BASED HEALTH CARE SERVICES

NEW SECTION. Sec. 16. LEGISLATIVE INTENT. The legislature finds that the good health of the citizens in the state through the reduction of mortality and morbidity and the promotion of good health should be the prime objective of state health-related activities. The legislature further finds that the availability of population-based health services such as health promotion, community health protection, personal clinical preventative services, and services related to the access to these health services is essential for meeting this state policy objective. The availability of these population-based services is contingent upon the existence of an ongoing and functioning capacity to assess health status, develop public policy to promote and maintain good health, and assure the provision of services through adequate administrative and service capabilities that engage in appropriate and effective health interventions.

The legislature further finds that the responsibility to provide population-based services involves many individuals and organizations in the private and public sector and at different levels of government.

The legislature declares that state public policy on health interest is best served by assuring the availability of basic population-based health services throughout the state including the administrative structure and capacity to provide and maintain such services.

NEW SECTION. Sec. 17. STATE POPULATION-BASED ESSENTIAL HEALTH SERVICES PLAN‑-CONTENT AND EVALUATION. By October 1, 1992, the department, in consultation with the board, the departments of agriculture and ecology, and local health jurisdictions, shall prepare a state population-based health services plan. The purpose of the plan is to identify the core functions and services necessary to assure the presence of a state-wide population-based health care system capable of providing essential population-based health care services.

(1) The state population-based health services plan shall identify existing and new activities necessary to maintain the state-wide population-based health services system. The plan shall specifically describe how the following core function and service elements will be assured:

(a) An ongoing capability to assess the health status and health-related conditions and trends in the state through the utilization of data collection and analysis from public and private sources, including the state health report as required under RCW 43.20.050;

(b) An ongoing capability to develop public policy objectives for health based on the assessment to identify state population-based essential health needs, set state-wide priorities among identified health needs, establish goals and measurable outcome-based objectives to address priority needs, and develop policy implementation strategies that include the identification of necessary resources to meet priority needs; and

(c) An ongoing capability to provide services to address the identified population-based essential health needs, or the identification of other public or private entities responsible for the provision of such services. In addition to the services specified in subsection (2) of this section, it shall also include the capacity of the state and local health jurisdictions to respond to critical situations and emergencies that jeopardize public health.

(2) The plan shall identify specific activities necessary to assure the provision of the following population-based essential health services:

(a) Services related to health promotion that may include, but not be limited to, the areas of physical activity and fitness, nutrition, community education in substance abuse avoidance, and parenting;

(b) Services related to community health protection that may include, but not be limited to, injury control, safe water, food, housing and waste management, air quality, and facility and professional licensure; and

(c) Services related to personal disease prevention that may include, but not be limited to, immunizations, screenings, communicable disease control, and chronic disease management.

(3) The department shall assure the active participation of entities interested in the development of population-based health services policy objectives. Such entities shall include, but not be limited to, consumers, providers, insurers, businesses, other state agencies, and appropriate academic teaching and research institutions. The plan shall specify how such groups and individuals will be involved.

(4) The department shall periodically evaluate the progress made toward meeting the essential population-based health care needs of the state. This evaluation shall be based upon the use of outcome measures and targets.

NEW SECTION. Sec. 18. LOCAL POPULATION-BASED HEALTH SERVICES PLANS‑-CONTENT AND EVALUATION. (1) By June 1, 1993, each local health officer shall prepare a local health department population-based health services plan in accordance with the provisions of this section. The plan shall be approved by the secretary in accordance with section 19 of this act. The purpose of the plan is to identify the core services and functions necessary to assure the presence of a local population-based health care system capable of providing essential population-based health care services in the local health jurisdiction. The plan shall identify how it will meet the policy objectives and service requirements specified in the state-wide plan under section 17 of this act. Approval of the plan is required for the receipt of funding as provided for under this act.

(2) The local population-based health services plan shall identify existing and new activities necessary to maintain the jurisdiction's population-based health services system. It shall specifically describe how the following core function and service elements will be assured:

(a) The ongoing capability to assess the health status and health-related conditions and trends in the local health jurisdiction through the utilization of data collection and analysis from public and private sources;

(b) The ongoing capability to develop public policy objectives for health based on the assessment to identify population-based essential health needs, set priorities among identified health needs, establish goals and measurable outcome-based objectives to address priority needs, and develop policy implementation strategies that include the identification of necessary resources to meet priority needs; and

(c) The ongoing capability to provide services to address the identified population-based essential health needs, or the identification of other public or private entities responsible for the provision of such services. In addition to the services specified in subsection (3) of this section, it also includes the capacity of the local health jurisdiction to respond to critical situations and emergencies that jeopardize public health.

(3) The plan shall identify activities necessary to assure the provision of the following population-based essential health services:

(b) Services related to community health protection that may include, but not be limited to, community injury control, safe water, food, housing and waste management, air quality, and facility and professional licensure; and

(c) Services related to personal disease prevention that may include, but not be limited to, immunizations, screenings, communicable disease control, and chronic disease management.

(4) Two or more local health jurisdictions may, through agreement, jointly provide services specified in this section if such joint provision results in greater efficiencies and economies in the system or increases access to services. Such joint agreements must be approved by the department.

(5) The local health jurisdictions shall periodically evaluate progress made toward meeting the essential population-based health care needs of the jurisdiction. The system of evaluation shall use outcome measures and targets to evaluate the system's progress.

(6) The local health jurisdiction shall identify funding sources in addition to any funds appropriated under this act to support the population-based health services system. Any funding provided for by this act is not intended to supplant funding provided from other sources.

(7) The local health jurisdiction shall assure the active participation of entities interested in the development of population-based health services policy objectives. Such entities shall include, but not be limited to, consumers, providers, businesses, insurers, community leaders, and other interested parties.

NEW SECTION. Sec. 19. POPULATION-BASED ESSENTIAL HEALTH SERVICES PLAN‑-LOCAL PLAN APPROVAL‑-OTHER DEPARTMENT DUTIES. (1) The department shall review and approve local population-based health services plans submitted by local health jurisdictions. The secretary shall specify the format and timeline for such submissions. In reviewing each local plan, the department shall determine whether:

(a) Proposed policies, services, and activities reasonably and adequately address identified health care needs, that adequate outcome measures will be used to indicate progress toward meeting identified needs, and that sufficient resources have been identified to operate the population-based health services system;

(b) The local health jurisdiction has specified activities necessary to provide for the services and functions identified in the state population-based health services plan;

(c) Multilocal health jurisdiction joint agreements should be pursued in order to address one or more elements of the local plan;

(d) Joint agreements for multijurisdictional activities proposed in the local plan are justified and should be approved; and

(e) Adequate local capabilities exist to evaluate and report to the department on progress in meeting the population-based health care needs of the local jurisdiction.

(2) The department shall expeditiously review and approve or recommend specific modifications to the local plans. Local health jurisdictions shall be given an opportunity to respond to recommendations for the modification of the plan. An appeal process shall be established by the department to review appeals of disputes.

(3) Within ninety days after the effective date of this act, the department shall devise a funding distribution formula for the purpose of allocating funds appropriated under this act to local health jurisdictions when local plans have been approved. The formula shall include projections of funding needs to provide for the local population-based health service needs of each local health jurisdiction. The formula shall take into consideration differences between the local health jurisdictions with respect to demographic features of the population, workload, and other such factors that affect the ability to provide the services and functions in the local plans. The department shall include means for determining the distribution of funding in those circumstances where multijurisdictional joint agreements have been approved. Funding appropriated under this act for essential population-based services shall be used solely for activities related to sections 16 through 19 of this act. Funding authorized under this act shall not supplant funding from other sources.

(4) The department shall prepare a local population-based health services plan for any local health department which fails or refuses to meet its responsibilities under this chapter. In such cases, the department may contract with such entities as is necessary to provide for services or functions of the local population-based health services system. It shall use such funds appropriated under this act and intended for local health jurisdictions for such purposes.

Sec. 20. RCW 43.20.050 and 1989 1st ex.s. c 9 s 210 and 1989 c 207 s 1 are each reenacted and amended to read as follows:

(1) The state board of health shall provide a forum for the development of health policy in Washington state. It is authorized to recommend to the secretary means for obtaining appropriate citizen and professional involvement in all health policy formulation and other matters related to the powers and duties of the department. It is further empowered to hold hearings and explore ways to improve the health status of the citizenry.

(a) At least every five years, the state board shall convene regional forums to gather citizen input on health issues.

(b) Every two years, in ((~~coordination with~~)) advance of the development of the state biennial budget and in coordination with the development of the state and local population-based public health service system objectives as provided for in sections 17 and 18 of this act, the state board shall prepare the state health report that outlines the health priorities of the ensuing biennium and provides information for use in development of the state and local population-based public health service system objectives as provided under sections 17 and 18 of this act. The report shall:

(i) Consider the citizen input gathered at the health forums;

(ii) Be developed with the assistance of local health departments;

(iii) Be based on the best available information collected and reviewed according to RCW 43.70.050 and recommendations from the council;

(iv) Be developed with the input of state health care agencies. At least the following directors of state agencies shall provide timely recommendations to the state board on suggested health priorities for the ensuing biennium: The secretary of social and health services, the health care authority administrator, the insurance commissioner, the administrator of the basic health plan, the superintendent of public instruction, the director of labor and industries, the director of ecology, and the director of agriculture;

(v) Be used by state health care agency administrators in preparing proposed agency budgets and executive request legislation;

(vi) Be submitted by the state board to the governor by ((~~June~~)) January 1 of each even-numbered year for adoption by the governor. The governor, no later than ((~~September~~)) April 1 of that year, shall approve, modify, or disapprove the state health report.

(c) In fulfilling its responsibilities under this subsection, the state board shall create ad hoc committees or other such committees of limited duration as necessary. Membership should include legislators, providers, consumers, bioethicists, medical economics experts, legal experts, purchasers, and insurers, as necessary.

(2) In order to protect public health, the state board of health shall:

(a) Adopt rules ((~~and regulations~~)) necessary to assure safe and reliable public drinking water and to protect the public health. Such rules ((~~and regulations~~)) shall establish requirements regarding:

(i) The design and construction of public water system facilities, including proper sizing of pipes and storage for the number and type of customers;

(ii) Drinking water quality standards, monitoring requirements, and laboratory certification requirements;

(iii) Public water system management and reporting requirements;

(iv) Public water system planning and emergency response requirements;

(v) Public water system operation and maintenance requirements; and

(vi) Water quality, reliability, and management of existing but inadequate public water systems.

(b) Adopt rules ((~~and regulations~~)) and standards for prevention, control, and abatement of health hazards and nuisances related to the disposal of wastes, solid and liquid, including but not limited to sewage, garbage, refuse, and other environmental contaminants; adopt standards and procedures governing the design, construction, and operation of sewage, garbage, refuse and other solid waste collection, treatment, and disposal facilities;

(c) Adopt rules ((~~and regulations~~)) controlling public health related to environmental conditions including but not limited to heating, lighting, ventilation, sanitary facilities, cleanliness and space in all types of public facilities including but not limited to food service establishments, schools, institutions, recreational facilities and transient accommodations and in places of work;

(d) Adopt rules ((~~and regulations~~)) for the imposition and use of isolation and quarantine;

(e) Adopt rules ((~~and regulations~~)) for the prevention and control of infectious and noninfectious diseases, including food and vector borne illness, and rules ((~~and regulations~~)) governing the receipt and conveyance of remains of deceased persons, and such other sanitary matters as admit of and may best be controlled by universal rule; and

(f) Adopt rules for accessing existing data bases for the purposes of performing health related research.

(3) The state board may delegate any of its rule-adopting authority to the secretary and rescind such delegated authority.

(4) All local boards of health, health authorities and officials, officers of state institutions, police officers, sheriffs, constables, and all other officers and employees of the state, or any county, city, or township thereof, shall enforce all rules ((~~and regulations~~)) adopted by the state board of health. In the event of failure or refusal on the part of any member of such boards or any other official or person mentioned in this section to so act, he or she shall be subject to a fine of not less than fifty dollars, upon first conviction, and not less than one hundred dollars upon second conviction.

(5) The state board may advise the secretary on health policy issues pertaining to the department of health and the state.

Sec. 21. RCW 43.70.050 and 1989 1st ex.s. c 9 s 107 are each amended to read as follows:

(1) The legislature intends that the department, board, and council promote and assess the quality, cost, and accessibility of health care throughout the state as their roles are specified in this act in accordance with the provisions of this chapter. In furtherance of this goal, the secretary shall create an ongoing program of data collection, storage, ((~~assessibility~~)) accessibility, and review. The legislature does not intend that the department conduct or contract for the conduct of basic research activity. The secretary may request appropriations for studies according to this section from the legislature, the federal government, or private sources.

(2) All state agencies which collect or have access to population-based, health-related data are directed to allow the secretary access to such data. This includes, but is not limited to, data on needed health services, facilities, and personnel; future health issues; emerging bioethical issues; health promotion; recommendations from state and national organizations and associations; and programmatic and statutory changes needed to address emerging health needs. Private entities, such as insurance companies, health maintenance organizations, and private purchasers are also encouraged to give the secretary access to such data in their possession. The secretary's access to and use of all data shall be in accordance with state and federal confidentiality laws and ethical guidelines. Such data in any form where the patient or provider of health care can be identified shall not be disclosed, subject to disclosure according to chapter 42.17 RCW, discoverable or admissible in judicial or administrative proceedings. Such data can be used in proceedings in which the use of the data is clearly relevant and necessary and both the department and the patient or provider are parties.

(3) The department shall serve as the clearinghouse for information concerning innovations in the delivery of health care services, the enhancement of competition in the health care marketplace, and federal and state information affecting health care costs.

(4) The secretary shall review any data collected, pursuant to this chapter, to:

(a) Identify high-priority health issues that require study or evaluation. Such issues may include, but are not limited to:

(i) Identification of variations of health practice which indicate a lack of consensus of appropriateness;

(ii) Evaluation of outcomes of health care interventions to assess their benefit to the people of the state;

(iii) Evaluation of specific population groups to identify needed changes in health practices and services;

(iv) Evaluation of the risks and benefits of various incentives aimed at individuals and providers for both preventing illnesses and improving health services;

(v) Identification and evaluation of bioethical issues affecting the people of the state; and

(vi) Other such objectives as may be appropriate;

(b) Further identify a list of high-priority health study issues for consideration by the board or council, within their authority, for inclusion in the state health report required by RCW 43.20.050. The list shall specify the objectives of each study, a study timeline, the specific improvements in the health status of the citizens expected as a result of the study, and the estimated cost of the study; ((~~and~~))

(c) Use such data, research, and findings in preparation of the state and local population-based health services plan as authorized by sections 17 and 18 of this act; and

(d) Provide background for the state health report required by RCW 43.20.050.

(5) Any data, research, or findings may also be made available to the general public, including health professions, health associations, the governor, professional boards and regulatory agencies and any person or group who has allowed the secretary access to data.

(6) The secretary may charge a fee to persons requesting copies of any data, research, or findings. The fee shall be no more than necessary to cover the cost to the department of providing the copy.

PART III - CHILDHOOD IMMUNIZATIONS

NEW SECTION. Sec. 22. INTENT‑-DECLARATION. The legislature finds that:

(1) There has been an increase in the number of children contracting vaccine preventable infectious diseases;

(2) This trend has occurred despite the availability of safe and effective immunizations which can prevent these disabling and life-threatening diseases;

(3) Parents and guardians of children are often unaware of the need for immunizations, the appropriate age to receive such immunizations, and the public health risks of the failure to be properly immunized;

(4) Adults may not be aware of their risk of contracting vaccine preventable infectious diseases and the availability of effective immunizations.

The legislature declares that it is in the public health interest of the people of the state of Washington that all adults and children should be appropriately immunized.

NEW SECTION. Sec. 23. STATE BOARD OF HEALTH‑-IMMUNIZATION SCHEDULE. (1) The state board of health shall adopt rules by October 1, 1992, that establish a schedule of appropriate immunizations against vaccine preventable infectious diseases for adults and children. The schedule shall include the type of immunization recommended and the appropriate age for receiving vaccines. The state board may modify by rule the recommended immunization schedule. When implementing this section the state board shall consider recommended immunization schedules developed by such entities as the federal center for disease control and the United States public health services.

(2) The state board shall make immunization schedules required by this section available to the secretary of health, the secretary of social and health services, the administrator of the basic health plan, the administrator of the state health care authority, and the general public no later than November 1, 1992.

NEW SECTION. Sec. 24. DEMONSTRATION PROJECTS TO INCREASE IMMUNIZATION RATES AMONG CHILDREN RECEIVING STATE-PAID SOCIAL AND HEALTH SERVICES. (1) Effective January 1, 1993, the secretary, in consultation with the department of social and health services, shall establish five demonstration projects for the purpose of increasing immunization utilization rates among children who are recipients of state-paid social and health care services or who are members of an at-risk population. The projects shall be established to identify the most effective, cost-efficient, and least burdensome manner to incorporate efforts to meet immunization target rates as a part of such programs. The secretary shall utilize age-appropriate immunization against infectious disease target rates as established in the state population-based health services plan authorized under this chapter. In no case shall the expected target rate for the projects be less than an immunization compliance rate of ninety percent for each age group. If the secretary determines that a pilot project has not met, or appears to be unable to meet, the minimum target rate six months after initial implementation of the project, the secretary shall discontinue the project and authorize another project in the same or different location.

In selecting demonstration project sites the secretary shall select sites in both rural and urban areas of the state and in areas east and west of the Cascade mountains. The projects shall be structured in a manner to permit the evaluation of different approaches to enhance immunization utilization rates among the population. In meeting the requirements of this section the secretary shall establish four of the five project sites using specific state-administered social and health service programs for children.

(2) The projects shall terminate on December 1, 1994, and the secretary and the secretary of social and health services shall report to the standing health care committees of the senate and house of representatives by December 15, 1994, on the following:

(a) An evaluation of the effectiveness of the various methods used to enhance immunization rates;

(b) A proposal indicating which methods are to be used to meet the immunization requirements in sections 25 and 26 of this act beginning in January 1995; and

NEW SECTION. Sec. 25. STATE SERVICE RECIPIENTS--DEPARTMENT OF SOCIAL AND HEALTH SERVICES. (1) Effective January 1, 1995, the parent or legal guardian of a child who is eligible to receive services from, through, or purchased by the department shall be responsible for providing to the department within ninety days of receiving such services:

(a) A certificate showing that the child has completed the state board of health recommended infectious disease immunization schedule or is making satisfactory progress in complying with the schedule;

(b) A waiver signed by a physician licensed under chapter 18.71 or 18.57 RCW stating that a particular vaccine is not medically advisable for the child. When it is determined by the physician that a particular vaccine is not contraindicated, the child will be required to receive the immunization;

(c) A written certification signed by a parent or legal guardian of the child stating that the signer has objections to the required immunizations based upon religious beliefs; or

(d) A written certification signed by a parent or legal guardian of the child stating that the signer has either a philosophical or personal objection to immunizing the child.

(2) The secretary shall grant to parents or guardians of children who are receiving department services on or before January 1, 1995, ninety days to comply with the requirements of this section.

(3) The secretary shall decide the manner in which certificates and waivers required by this section shall be prepared and made available.

(4) The secretary may establish by rule a procedure to periodically check whether children are making satisfactory progress in complying with the appropriate immunization schedules. Such monitoring shall, to the extent possible, be conducted during the course of routine contact with the parent or guardian of the child.

(5) The secretary shall coordinate with the secretary of health, in the preparation of certificates and waivers required for the administration of this section to assure minimum paperwork and prevent duplicative compliance requirements for children receiving state services or benefits from more than one state agency.

(6) The secretary shall seek whatever federal waivers are necessary to implement the provisions of this section.

NEW SECTION. Sec. 26. STATE SERVICE RECIPIENTS--DEPARTMENT OF HEALTH. (1) Effective January 1, 1995, the parent or guardian of a child who is eligible to receive services from, through, or purchased by the department shall be responsible for providing to the department within ninety days of receiving such services:

(c) A written certification signed by a parent or legal guardian of the child stating that the signer has objections to the required immunizations based upon religious beliefs; or

(d) A written certification signed by a parent or legal guardian of the child stating that the signer has either a philosophical or personal objection to immunizing the child.

(2) The secretary shall grant to parents or guardians of children who are receiving department services on or before January 1, 1995, ninety days to comply with the requirements of this section.

(3) The secretary shall decide the manner in which certificates and waivers required by this section may be prepared and made available.

(5) The secretary shall coordinate with the secretary of social and health services in the preparation of certificates and waivers and required for the administration of this section to assure minimum paperwork and duplicative compliance requirements for children receiving state services or benefits from more than one state agency.

(6) The secretary shall seek whatever federal waivers are necessary to implement the provisions this section.

NEW SECTION. Sec. 27. STATE SUBSIDIZED HEALTH CARE INSURANCE RECIPIENTS--BASIC HEALTH PLAN. (1) Effective January 1, 1995, the parent or guardian of a child who is enrolled in the plan shall be responsible for providing to the plan administrator within ninety days of enrollment:

(c) A written certification signed by a parent or legal guardian of the child stating that the signer has objections to the required immunizations based upon religious beliefs; or

(d) A written certification signed by a parent or legal guardian of the child stating that the signer has either a philosophical or personal objection to immunizing the child.

(2) The administrator shall grant to parents and guardians of children enrolled in the plan on or before January 1, 1995, ninety days to comply with the requirements of this section.

(3) The administrator shall decide the manner in which certificates and waivers required by this section shall be prepared and made available.

(4) The administrator may establish by rule a procedure to periodically check whether children are making satisfactory progress in complying with the appropriate immunization schedules. Such monitoring shall, to the extent possible, be conducted when the parent or guardian of the child has routine contact with the plan or health care contractors authorized to provide services under the plan.

NEW SECTION. Sec. 28. STATE EMPLOYEE BENEFIT RECIPIENTS--STATE HEALTH CARE AUTHORITY. (1) Effective January 1, 1995, the parent or guardian of a child who is enrolled as a dependent in the plan shall be responsible for providing to the administrator within ninety days of enrollment:

(c) A written certification signed by a parent or legal guardian of the child stating that the signer has objections to the required immunizations based upon religious beliefs; or

(d) A written certification signed by a parent or legal guardian of the child stating that the signer has either a philosophical or personal objection to immunizing the child.

(2) The administrator shall grant to parents and guardians of children enrolled in the plan on or before January 1, 1995, ninety days to comply with the requirements of this section.

(3) The administrator shall decide the manner in which certificates and waivers required by this section shall be prepared and made available.

(4) The administrator may establish by rule a procedure to periodically check whether children are making satisfactory progress in complying with the appropriate immunization schedules. Such monitoring shall, to the extent possible, be conducted when the parent or guardian of the child has any routine contact with the plan or health care contractors authorized to provide services under the plan.

NEW SECTION. Sec. 29. IMMUNIZATION ASSESSMENT AND ENHANCEMENT PROPOSALS. (1) The department shall require that each local health jurisdiction submit an immunization assessment and enhancement proposal as part of the local population-based health services plan required in section 18 of this act. The proposal shall meet the requirements of this section. It shall include a description of how the local health jurisdictions will consult and involve existing health care providers that have previously been involved in the administration of state-supplied immunizations or have shown an interest to become involved.

(2) A local health jurisdiction must include at least the following in the proposal:

(a) A description of the population groups in the jurisdiction that are in greatest need for immunizations;

(b) A description of providers in the jurisdiction that are capable and willing to administer immunizations and how the providers will be utilized in enhancing immunization compliance with established target rates;

(c) A description of steps to meet immunization compliance target rates set forth in the state population-based health services plan authorized by this chapter;

(d) A description of current fees charged to patients used to support local immunization efforts;

(e) An analysis of financial and nonfinancial barriers that are preventing children from receiving immunizations and a description of how the jurisdiction will remove such barriers; and

(f) A description of strategies to use outreach, volunteer, and other local educational resources to enhance immunization rates.

(3) The secretary shall approve the immunization assessment and enhancement proposal as part of the approval of the local population-based health services plan.

(4) This section shall be implemented consistent with available funding.

(5) The funding authorized under this act shall be used to supplement but not replace current fees used to support local immunization efforts that are charged to patients.

(6) The secretary shall report biennially to the health care and fiscal committees of the house of representatives and senate on the status of the program and progress made toward meeting the target immunization target rates.

Sec. 30. RCW 28A.210.070 and 1990 c 33 s 191 are each amended to read as follows:

As used in RCW 28A.210.060 through 28A.210.170:

(1) "Chief administrator" shall mean the person with the authority and responsibility for the immediate supervision of the operation of a school or day care center as defined in this section or, in the alternative, such other person as may hereafter be designated in writing for the purposes of RCW 28A.210.060 through 28A.210.170 by the statutory or corporate board of directors of the school district, school, or day care center or, if none, such other persons or person with the authority and responsibility for the general supervision of the operation of the school district, school or day care center.

(2) "Full immunization" shall mean immunization against certain vaccine-preventable diseases in accordance with schedules and with immunizing agents approved by the state board of health.

(3) "Local health department" shall mean the city, town, county, district or combined city-county health department, board of health, or health officer which provides public health services.

(4) "School" shall mean and include each building, facility, and location at or within which any or all portions of a preschool, kindergarten and grades one through twelve program of education and related activities are conducted for two or more children by or in behalf of any public school district and by or in behalf of any private school or private institution subject to approval by the state board of education pursuant to RCW 28A.305.130(6), 28A.195.010 through 28A.195.050, and 28A.410.120.

(5) "Day care center" shall mean an agency which regularly provides care ((~~for a group of thirteen or more~~)) to children for periods of less than twenty-four hours and is licensed pursuant to chapter 74.15 RCW.

(6) "Child" shall mean any person, regardless of age, in attendance at a public or private school or a licensed day care center.

PART IV - REGIONAL HEALTH PROMOTION

NEW SECTION. Sec. 31. LEGISLATIVE FINDINGS. The legislature finds that:

(1) The current system of health care and public health has been remarkably successful in identifying and reducing or eradicating many contagious or infectious diseases that were major public health threats in years past.

(2) Chronic diseases account for three out of four deaths in Washington every year. Diseases such as heart disease, cancer, intentional and unintentional injuries, perinatal conditions, and other conditions can be prevented if individuals receive early detection of disease and periodic screening, and modify their personal behaviors and life styles.

(3) State, local, and private agencies have been established to plan and deliver social and health services. Many of these services are designed to arrest, treat, or cure illnesses and injuries, not to prevent them.

(4) While certain state agencies have responsibility for prevention of particular illnesses or injuries, such as the Washington traffic safety commission for prevention of traffic injuries and the department of social and health services for prevention of substance abuse, no single entity in state or local government is presently charged with the authority to oversee and coordinate all public and private efforts to address the factors which will promote health and prevent illness and injury, both intentional and unintentional. Of particular concern is the need to coordinate and lead existing public and private efforts to deal with chronic disease and its causes including tobacco use, misuse of alcohol and other drugs, intentional and unintentional injuries, diet, or other personal behaviors.

(5) These activities are essential to the protection and promotion of public health and should be pursued by individual citizens, communities, local governments, businesses, and public and private agencies with leadership from local health departments, the department of health, and the board of health through the state health report.

The purpose of sections 32 through 34 of this act is to provide health promotion and disease and injury prevention efforts within the public health system to empower individuals, voluntary community associations, health organizations, and others by providing information and resources to protect and promote health.

NEW SECTION. Sec. 32. CENTER FOR HEALTH PROMOTION ESTABLISHED. There is established within the department of health a center for health promotion and disease and injury prevention whose principal administrator shall report to the secretary. The center shall contain departmental functions that the secretary determines are most directly related to the promotion of health and the prevention of diseases and intentional and unintentional injuries, consistent with the organizational principles set forth in RCW 43.70.020.

(1) Included as part of the state-wide population-based health services plan, the center shall assist the department to:

(a) Identify the leading causes of death, disease, and injury to Washington citizens;

(b) Isolate the causes and risk factors for these illnesses and injuries, both intentional and unintentional;

(c) Identify geographic areas and population groups at risk for these illnesses and intentional and unintentional injuries;

(d) Identify strategies that have been demonstrated to be effective in reducing these illnesses, intentional and unintentional injuries, causes, or risk factors.

(2) Biennially the center shall establish health promotion and disease and injury prevention state-wide objectives. It shall consult with the local health jurisdictions and state board of health and shall consider such appropriate objectives as may be found in the state health report and United States public health service year 2000 objectives. Using data on Washington residents, the department shall adopt state-wide objectives in a manner that addresses at least the following national objectives to be achieved by the year 2000:

(a) Reduce cigarette smoking among people twenty years and over from 29.1 percent to no more than fifteen percent;

(b) Reduce cigarette smoking among people less than twenty years from 29.5 percent to no more than fifteen percent;

(d) Reduce prevalence of cholesterol levels of two hundred forty milligrams per deciliter among people twenty and older from 26.8 percent to no more than twenty percent;

(e) Reduce deaths from cancer of the uterine cervix from 3.2 per one hundred thousand women to no more than 1.5 per one hundred thousand women;

(f) Reduce serious nonfatal head injuries from one hundred eleven per one hundred thousand people to no more than eighty-three per one hundred thousand;

(g) Reduce drowning deaths from 2.6 per one hundred thousand persons to no more than 1.7 per one hundred thousand persons;

(h) Improve control of diabetes, as measured by a reduction in hospitalization from 13.8 per one thousand people with diabetes to 6.9 per one thousand people with diabetes;

(i) Reverse the rising incidence of physical abuse of children under age eighteen from 10.7 per one thousand children to no more than 10 per one thousand children;

(j) Reduce assault injuries among people age twelve and older from 1841.8 per one hundred thousand people to no more than 1650 per one hundred thousand people;

(k) Reduce alcohol-related motor vehicle crash deaths from 9.7 per one hundred thousand people to 8.5 per one hundred thousand people;

(l) Reduce by fifty percent the use of alcohol, marijuana, and cocaine among young people ages twelve to seventeen years from 25.2 percent for alcohol, 6.4 percent for marijuana, and 1.1 percent for cocaine;

(m) Reduce annual average alcohol consumption by people age fourteen and older by twenty-three percent from 2.6 gallons of ethanol per year to 2 gallons of ethanol per year;

(n) Reduce by twenty-five percent the number of infants born to chemical abusing women; and

(o) Reduce the incidence of gonorrhea from 297 cases per one hundred thousand people to 225 cases per one hundred thousand people.

(3) The center shall also:

(a) Act as a clearinghouse and consultive resource for local health departments, other public and private groups, and voluntary community associations that wish to implement these strategies; and

(b) Request and receive funds, gifts, grants, or appropriations from the legislature, the federal government, or private sources to pursue the department's duties under this section.

NEW SECTION. Sec. 33. HEALTH PROMOTION AND DISEASE PREVENTION REGIONS. The department shall establish a state-wide system of health promotion and disease prevention regions as follows:

(1) The department, in collaboration with local health jurisdictions, shall designate regions and assist these regions in establishing local health promotion and disease and intentional and unintentional injury prevention priority objectives based on analysis of the information in section 32 of this act. Regions shall be consistent with the organizational principles in this chapter, except as necessary to promote efficiency and responsiveness in programs, and, to the extent possible, reflect unique grouping of disease or injury incidence or populations identified at risk.

(2) The department, in consultation with the state board of health, shall designate regions incorporating the entire state by October 1, 1992, and shall identify such regions in the state population-based health services plan.

(3) By June 1, 1993, each region shall prepare, through a cooperative effort of local health jurisdictions, other health care providers, schools, community, business, and health organizations within the region, a regional health promotion and disease and intentional and unintentional injury prevention proposal that addresses the objectives established under subsection (1) of this section. The proposal shall be incorporated into the local population-based health services plan required by section 18 of this act. It shall place emphasis on collaboration with local voluntary organizations within the region.

(4) Health promotion and disease and intentional and unintentional injury prevention interventions under sections 32 through 34 of this act shall include measures with demonstrated effectiveness in meeting regional health promotion and disease and intentional and unintentional injury prevention objectives. Interventions may include at least health screening services and assessments, public education campaigns, and targeted education efforts. In no case may interventions under sections 32 through 34 of this act include the delivery of primary health or social services.

(5) In developing intervention strategies regarding the health of children and adolescents, the region shall cooperate with all local school districts within the region. It is the region's obligation to involve local school districts in planning these interventions for children and adolescents. If a local school district declines to participate, the school district shall submit a written statement to this effect to the region. This statement must be included in the regional health promotion and disease and intentional and unintentional injury prevention proposal.

(6) The regional health promotion and disease and intentional and unintentional injury prevention proposal shall be developed and administered by the local public health jurisdiction within the region. If a region encompasses more than one local public health jurisdiction, those jurisdictions shall select a jurisdiction to develop and administer the regional proposal. In the event agreement cannot be reached, the department shall determine the lead jurisdiction.

(7) Authorized funding for health promotion and disease and intentional and unintentional injury prevention regions shall be allocated in grants based on priorities established under subsection (1) of this section and the cost efficiencies of interventions associated with those priorities.

NEW SECTION. Sec. 34. The state board of health shall review the health promotion and disease and intentional and unintentional injury prevention objectives established in section 32 of this act and recommend modification as part of the state health report.

Sec. 35. RCW 43.59.030 and 1991 c 3 s 298 are each amended to read as follows:

The governor shall be assisted in his or her duties and responsibilities by the Washington state traffic safety commission. The Washington traffic safety commission shall be composed of the governor as ((~~chairman~~)) chair, the superintendent of public instruction, the director of licensing, the secretary of transportation, the chief of the state patrol, the secretary of health, the secretary of social and health services, a representative of the association of Washington cities to be appointed by the governor, a member of the association of counties to be appointed by the governor, and a representative of the judiciary to be appointed by the governor. Appointments to any vacancies among appointee members shall be as in the case of original appointment.

The governor may designate an employee of the governor's office to act on behalf of the governor during the absence of the governor at one or more of the meetings of the commission. The vote of the designee shall have the same effect as if cast by the governor if the designation is in writing and is presented to the person presiding at the meetings included within the designation.

The governor may designate a member to preside during the governor's absence.

PART V - COMMUNITY OUTREACH FOR HEALTH

NEW SECTION. Sec. 36. LEGISLATIVE INTENT. The legislature finds that current health and social service outreach programs focus primarily on multimedia campaigns, telephone hotlines, and professional case finding and referrals. These programs may fail to address the access barriers experienced by high-risk pregnant and parenting women and their families. The legislature finds that active outreach programs using indigenous, nonprofessional community members and resources offer unique credibility and supports that cannot be duplicated by professional efforts or multimedia campaigns. The legislature further finds that indigenous community outreach programs achieve health improvements comparable or superior to professional or educational outreach programs.

The purpose of this section and section 37 of this act is to empower individuals, businesses, voluntary community organizations, and others to promote health and prevent illness and injury among high-risk pregnant and parenting women and their families in their local community through active outreach programs using indigenous, nonprofessional community members and resources.

NEW SECTION. Sec. 37. COMMUNITY OUTREACH PILOT PROGRAMS. The secretary shall assist local health jurisdictions in establishing ten pilot local community outreach for health programs using indigenous, nonprofessional community volunteers. Local health jurisdictions shall as part of the local population-based health services plan authorized by section 18 of this act: (1) Identify geographic areas and population groups experiencing substantial health risks among pregnant and parenting women and their families; and (2) develop and coordinate community outreach for health programs targeted toward at-risk geographic areas or population groups identified according to this section.

Community outreach programs shall focus on direct contact and may provide support, education, referral, or other activities that facilitate access to public and private community resources according to individual or family need.

Authorized funding for community outreach for health programs shall be allocated based on broad community participation, potential for health improvements and community empowerment. Applications for grants must provide a fifty percent match of funds or in-kind resources from local government, community organizations, or other private sources. Volunteer hours may be counted against this match at the rate of five dollars per hour.

PART VI - HEALTH SERVICES FOR SCHOOL CHILDREN

NEW SECTION. Sec. 38. LEGISLATIVE INTENT. The legislature finds that: (1) The availability of health care services in our schools promotes improved health of children in the state of Washington; (2) local health jurisdictions provide excellent health services and that collaboration between the local health jurisdictions and schools enhances the health of all children in the state; (3) the promotion of health services in the schools enhances the education of the students; and (4) in many districts school health services are not sufficient. The legislature declares that the availability of health services in the schools should be increased. It is the legislative intent to provide for the greatest degree of flexibility and cooperation between the school districts and local health departments in designing proposals for delivering health services that will respect the uniqueness of schools and local communities.

NEW SECTION. Sec. 39. (1) As part of the local population-based health services plan authorized under this chapter, each local health jurisdiction may assess the health services needs of children in grades K-8 in public and private schools. The purpose of the assessment is to identify needed school health services in grades K-8 in public and private schools as an enhancement to the current level of school health services. Funding authorized under this chapter shall not be used to supplant programs currently providing school health services.

(2) School districts may enter into contracts through interlocal agreements with local health jurisdictions for the provision of school health services upon approval by the department and having met the provisions of subsection (1) of this section. The interlocal agreements shall include but not be limited to: The type of services to be provided, the use of school facilities when school is not in session, supervision of health personnel while on school premises, the location of student health records, and the availability of student and parent education.

(3) The department shall provide funds, to the extent funds are appropriated by the legislature, to reimburse local health jurisdictions for school health services provided to school districts under subsection (2) of this section and based on the allocation model outlined in section 7 of this act. Neither the department nor the superintendent of public instruction may establish rules that will determine or forbid the services or level of services that are to be established in the interlocal agreements under subsection (2) of this section.

(4) The department shall submit a report to the legislature by December 1, 1993, describing the number of students served, the profiles of the schools and local health departments that have entered into interlocal agreements, benefits from the program, and any recommendations for improving the program.

PART VII - GATEKEEPER OUTREACH PROGRAM

NEW SECTION. Sec. 40. LEGISLATIVE FINDING. The legislature finds that moderately to severely impaired elderly who live in their own homes have traditionally been underserved by community-based agencies providing personal support services. Most moderately to severely impaired elderly do not self-refer for community-based services. The legislature further finds that health and social service agencies do not necessarily understand the community organization effort needed to identify and locate this large subpopulation of isolated, high-risk elderly. The legislature declares that active outreach programs using individuals who may have regular contact with the most isolated elderly living in their communities are highly successful in reaching this population.

Sec. 41. RCW 74.38.020 and 1989 1st ex.s. c 9 s 817 are each amended to read as follows:

As used in this chapter, the following words and phrases shall have the following meaning unless the content clearly requires otherwise:

(1) "Area agency" means an agency, other than a state agency, designated by the department to carry out programs or services approved by the department in a designated geographical area of the state.

(2) "Area plan" means the document submitted annually by an area agency to the department for approval which sets forth (a) goals and measurable objectives, (b) review of past expenditures and accounting of revenue for the previous year, (c) estimated revenue and expenditures for the ensuing year, and (d) the planning, coordination, administration, social services, and evaluation activities to be undertaken to carry out the purposes of the Older Americans Act of 1965 (42 U.S.C. Sec. 3024 et. seq.), as now or hereafter amended.

(3) "Department" means the department of social and health services.

(4) "Office" shall mean the office on aging which is the organizational unit within the department responsible for coordinating and administering aging problems.

(5) "Eligible persons" means senior citizens who are:

(a) Sixty-five years of age or more; or

(b) Sixty years of age or more and are either (i) nonemployed, or (ii) employed for twenty hours per week or less; and

(c) In need of services to enable them to remain in their customary homes because of physical, mental, or other debilitating impairments.

(6) "Low income" means initial resources or subsequent income at or below forty percent of the state median income as promulgated by the secretary of the United States department of health, education and welfare for Title XX of the Social Security Act, or, in the alternative, a level determined by the department and approved by the legislature.

(7) "Income" shall have the same meaning as in chapter 74.04 RCW, as now or hereafter amended; except, that money received from RCW 74.38.060 shall be excluded from this definition.

(8) "Resource" shall have the same meaning as in chapter 74.04 RCW, as now or hereafter amended.

(9) "Need" shall have the same meaning as in chapter 74.04 RCW, as now or hereafter amended.

(10) "Gatekeeper" means an employee of a federal, state, or local agency, corporation, business, or other entities that, in the course of his or her regular activities, have contact with the isolated elderly in the community. Gatekeepers include, but are not limited to, meter readers, repair personnel from the electrical and gas utilities, bank personnel, postal carriers, pharmacists, and emergency medical technicians.

NEW SECTION. Sec. 42. GATEKEEPER OUTREACH PROGRAM ESTABLISHED. The secretary shall assist area agencies in establishing gatekeeper outreach programs serving the communities in their service areas. The participating area agencies shall contract with existing community-based organizations actively engaged in the long-term care system to: (1) Recruit and train gatekeepers to identify and locate isolated high-risk elderly living in their community; (2) develop and implement a plan to facilitate access to public and private community resources for individuals identified through the gatekeeper program; and (3) report to the secretary annually on the effectiveness and impact of the program.

Authorized funding for gatekeeper outreach programs shall be allocated by the department through grants. Area agencies must provide a fifty percent match of funds or in-kind resources from the federal government, local government, community organizations, or other private sources.

PART VIII - MISCELLANEOUS

NEW SECTION. Sec. 43. CODIFICATION. Sections 1, 16, 17, 19, 22, 24, 26, 29, 31 through 33, and 36 through 39 of this act are each added to chapter 43.70 RCW.

NEW SECTION. Sec. 44. CODIFICATION. Section 18 of this act is added to chapter 70.05 RCW.

NEW SECTION. Sec. 45. CODIFICATION. Sections 23 and 34 of this act are each added to chapter 43.20 RCW.

NEW SECTION. Sec. 46. CODIFICATION. Section 25 of this act is added to chapter 43.20A RCW.

NEW SECTION. Sec. 47. CODIFICATION. Section 27 of this act is added to chapter 70.47 RCW.

NEW SECTION. Sec. 48. CODIFICATION. Section 28 of this act is added to chapter 41.05 RCW.

NEW SECTION. Sec. 49. CODIFICATION. Sections 40 and 42 of this act are each added to chapter 74.38 RCW.

NEW SECTION. Sec. 50. SEVERABILITY. If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.

NEW SECTION. Sec. 51. CAPTIONS NOT LAW. Section captions and part headings as used in this act do not constitute any part of the law.

NEW SECTION. Sec. 52. This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and shall take effect immediately.