Call to Order and Roll Call
Thefirst meeting of the Interim Joint Committee on Health and Welfare and Family Services was held on Wednesday, June 21, 2017, at 10:00 a.m., in Room 129 of the Capitol Annex. Senator Julie Raque Adams, Co-Chair, called the meeting to order at 10:05 a.m., and the secretary called the roll.
Members:Senator Julie Raque Adams, Co-Chair; Representative Addia Wuchner, Co-Chair; Senators Ralph Alvarado, Tom Buford, Danny Carroll, Julian M. Carroll, Denise Harper Angel, Alice Forgy Kerr, Stephen Meredith, Reginald Thomas, and Max Wise; Representatives Danny Bentley, George Brown Jr, Jim Gooch Jr., Joni L. Jenkins, Mary Lou Marzian, Chad McCoy, Russ A. Meyer, Kimberly Poore Moser, Melinda Gibbons Prunty, Steve Riley, and Russell Webber.
Guest Legislators: Senator Morgan McGarvey and Representative Al Gentry.
Guests: Bradley Stevenson, Executive Director, Shannon Smith, Government Relations, Child Care Council of Kentucky, Inc. ; Deck Decker, Executive Director, Office of Administrative and Technology Services, Cabinet for Health and Family Services; Joe Hamilton, Deputy Commissioner, Department for Community Based Services, Cabinet for Health and Family Services; Christa Bell, Director, Division of Childcare, Department for Community Based Services, Cabinet for Health and Family Services; Kathryn M. Callahan, Kentucky State Director, The Humane Society of the United States; Cynthia Gaskill, DVM, PhD, DABVT, University of Kentucky Veterinary Diagnostic Laboratory; Cindy Murray, Executive Director, Office for Policy and Budget, Cabinet for Health and Family Services; Alan Sisk, Executive Director, Office for Human Resources Management, Cabinet for Health and Family Services; Elizabeth Caywood, Executive Advisor, Department for Community Based Services, Cabinet for Health and Family Services; Eric Clark, Executive Advisor and Legislative Director, Cabinet for Health and Family Services; David Lovely, Attorney, Cabinet for Health and Family Services; Laura Begin, Office for Policy and Budget, Cabinet for Health and Family Services; Connie White, Senior Deputy Commissioner, Margaret Jones, Laura Harrod, Hollie Sands, and Janet Luttrell, Department for Public Health, Cabinet for Health and Family Services; Michelle Malicoti, Madison County School District; Mike Biagi, The Rotunda Group; Patty Swiney, Past President, Kentucky Academy of Family Physicians; Nathan Goldman, Kentucky Board of Nursing; Arica Brandfom; Michelle Anderson and Pam Cobban, Department for Community Based Services, Cabinet for Health and Family Services; Carol Komara, Kathy Hager, Lois Davis, Kentucky Nurses Association; Tracy Kielman, Kentucky Immunization Coalition; Chandra Venettozzi and D.J. Wasson, Office of Health Benefit Exchange, Cabinet for Health and Family Services; and Erika Calihan.
Legislative Hearing on Executive Order 2017-269, relating to Establishment and Operation of the Kentucky Office of Health Benefit Exchange
A motion to accept Executive Order 2017-269 was made by Senator Julian Carroll, seconded by Representative McCoy, and approved by voice vote. Cindy Murray, Executive Director, Office for Policy and Budget, and Alan Sisk, Executive Director, Office for Human Resources Management, Cabinet for Health and Family Services, were present for questions.
Legislative Hearing on the Community Services Block Grant
A motion to accept the Community Services Block Grant was made by Senator Alvarado, seconded by Representative Wuchner, and approved by voice vote. Elizabeth Caywood, Executive Advisor, Department for Community Based Services, Cabinet for Health and Family Services, was present to answer questions.
Legislative Hearing on the Social Services Block Grant
A motion to accept the Social Services Block Grant was made by Senator Alvarado, seconded by Representative Wuchner, and approved by voice vote. Elizabeth Caywood, Executive Advisor, Department for Community Based Services, Cabinet for Health and Family Services, was present to answer questions.
Consideration of Referred Administrative Regulations
The following administrative regulations were available for consideration: 201 KAR 20:056 – establishes the requirements for licensure, renewal, and reinstatement, education, and recognition of a national certifying organization for advanced practice registered nurses; 201 KAR 20:057 – establishes the scope and standards of practice for an advanced practice registered nurse; 900 KAR 10:041 – repeals 900 KAR 10:040 and 900 KAR 10:050 as these administrative regulations were rendered obsolete with the promulgation of 900 KAR 10:200, Kentucky State Based Exchange on the federal Platform; and 902 KAR 21:030 - establishes the Pediatric Cancer and Treatment Grant Program. A motion to approve 201 KAR 20:056, 201 KAR 20:057, 900 KAR 10:041, and 902 KAR 21:030 was made by Senator Alvarado, seconded by Representative Wuchner, and approved by voice vote.
Child Care Assistance Program
Bradley Stevenson, Executive Director, Child Care Council of Kentucky, stated that in 1997, the Child Care Assistance Program (CCAP) was privatized. From 1997 to 2009, the Child Care Council (CCC), 4C Louisville, Northern Kentucky ADD, Eastern Kentucky Child Care Coalition, and Audubon Area Community Services contracted to manage CCAP. In 2009 the cabinet released the Request for Proposal for the CCAP and awarded the contract to the Child Care Council. From 2009 to 2012, the CCC awarded contracts to Bluegrass, Eastern Kentucky, and Northern Kentucky regions through a model of centralizing and streamlining services. KIPDA and Audubon were added after 2012. All administrative services were centralized in Lexington, Louisville, and Elizabethtown. Centralized services include a call center, provider payments, fraud detection and prevention, registered provider processing, quality control of eligibility determination, and Web access for services. Since 2009, the CCC has submitted over 13,000 claims and submitted approximately $24 million for payment. In 2009, the contract for CCAP was $8,404,393 and $7,167,900 for 2017. The CCC has saved the Commonwealth a total of $7,294,467 over the past eight years. Of the $7,294,467 saved, $6,213,324 was saved since the full statewide centralization was implemented in 2013. The CCC currently employs 123 CCAP staff. Approximately 62% of the CCAP staff hold an Associates, Bachelors, or Master’s degree. On October 1, 2017, CCAP will be rolled into Benefind. The CCC’s contract with the Commonwealth will end on December 31, 2017.
Christa Bell, Director, Division of Childcare, Department for Community Based Services, Cabinet for Health and Family Services, stated that benefits of including CCAP in Benefind include increased access for families to move them toward self-sufficiency, more efficient customer service, fraud reduction, cost savings, improved error rates, reduced administrative burden, compliance with federal requirements, and better quality data. Families will have access to an eligibility worker in every county during business hours, which is currently not provided.
Approximately 93 percent of CCAP consumers are receiving at least one other type of assistance through Benefind. Consumers of Medicaid, KTAP, SNAP, and CCAP will have a single point of access to apply for benefits, recertify, or report changes. The cabinet would save $7.1 million by eliminating the CCC’s contract and have eligibility determinations made by current Family Support staff. Fifteen additional staff will be required to answer provider calls, process payments, and provider claims with a cost of $1 million annually. Two staff will be added to an existing contract with the Division of Regulated Child Care for visits to registered providers at a cost of $200,000 annually.
The CCC error rate has remained under the required threshold in contract deliverables, however, it is consistently over ten percent. By using shared data for all assistance programs, the CCAP error rate is expected to fall below six percent. Elimination of administrative oversight for a large contract including vendor payments, case reviews, and contract monitoring would reduce administrative burden. Processes will be streamlined and incorporated into existing structures, rather than having two separate structures performing the same functions separately.
The Child Care Development Block Grant Reauthorization Act of 2014 requires that applicants for child care subsidy be informed of other types of assistance for which they may be eligible. This requirement cannot be met under the current CCC contract since its staff are not able to make eligibility determinations for other assistance programs. Transition to Benefind will bring Kentucky into compliance with this requirement. Benefind will provide an enhanced data dashboard for consumers, allowing families to view detailed information about providers, compare options, and make an informed choice for quality care. Benefind will allow for extraction and comparison of data across multiple assistance programs.
In response to questions by Senator Danny Carroll, Ms. Bell stated that the cost of the contract versus staffing costs going forward should be approximately $3 million. There are approximately 2,100 licensed, certified, and registered providers statewide. There has been a decline of providers over the past five years. From 2012 to 2017, licensed providers has declined by approximately 300 providers. The cabinet is focused on recruitment efforts in areas statewide where there is not an adequate pool of providers to meet the needs of the community and has been in discussions with partnering agencies to try and increase providers to ensure needs are met statewide. An analysis is being conducted to see if the cost of moving from an attendance based payment to an enrollment based payment would help providers raise more money and bring Kentucky more into compliance with the national trend and federal standards.
Senator Alvarado stated that the CCAP savings will be great. There is a need to increase pay to providers.
Representative Wuchner stated that there is a need for more quality providers. The rate for child care providers has remained flat to date.
In response to questions by Senator Adams, Ms. Bell stated that the eligibility determination will be absorbed by current staff in the family support offices who already make determinations for other types of public assistance programs. Nine-three percent of CCAP recipients already have a case in Benefind because they are receiving some other type of public assistance. Fifteen additional positions will be filled in Frankfort to handle provider payments and claims not currently handled by family support staff. In anticipation of CCAP being transitioned to Benefind in 2016, eight of the fifteen positions have already been hired. Office hours are from 8:00 a.m. to 4:30 p.m. Monday through Friday for in all DCBS offices if someone has questions about Benefind or other public assistance programs.
In response to questions by Representative Jenkins, Joe Hamilton, Deputy Commissioner, Department for Community Based Services, Cabinet for Health and Family Services, stated that the cabinet has not applied for the federal Department for Health and Human Services’ Guardianship Assistance Program. Ms. Bell stated that from 2013 to 2106, families providing kinship care had access to child care assistance only during the time a protection and permanency case remained open. In 2016, with reauthorization requirements the administrative regulation changed to 12 months for eligibility. Families can renew the eligibility for however long a family needs child care assistance regardless whether the protection and permanency case remains open. Ms. Caywood stated that the Guardianship Assistance Program under Title III of the Social Security Act is being studied to see if it could enhance the array of services offered to eligible caregivers. The state would be responsible for a portion of all costs involved with the program.
In response to questions by Senator Wise, Ms. Bell stated that efficiency of services and cost savings are reasons to transition CCAP into Benefind. CCAP workers only determine eligibility for CCAP services, and new federal laws require an agency to be able to determine eligibility for all public assistance programs. There are no options for a federal waiver, because the new federal requirements went into effect in the fall of 2016.
In response to questions by Senator Julian Carroll, Deck Decker, Executive Director, Office of Administrative and Technology Services, Cabinet for Health and Family Services, stated that the decision to transition CCAP to Benefind was made by the Beshear administration and he was not sure who that administration met with before making this decision. The old system is out of compliance and there is no money to bring it into compliance. Kentucky has already received funds for Benefind, and if the child care enhancement is not transitioned to Benefind, Kentucky would have to reimburse the federal government for those funds. Mr. Stevenson stated that in 2014 discussions started to transition child care services into Benefind on December 28, 2015. The cabinet delayed the decision for two years to allow more discussions from providers on improvements to make it a smooth transition. Ms. Bell stated that 15 regional provider forums will be conducted statewide later during the summer.
In response to a question by Representative Moser, Ms. Bell stated that most states are facing the same challenges as Kentucky. It is a challenge to retain quality staff, because child care jobs are low paying jobs. Child care is not a lucrative business, and providers struggle to make ends meet. Providers are supported by CCAP funds but also by private pay funds. Families need to be able to afford child care. The cabinet is looking for ways to help providers with start-up costs.
In response to questions by Senator Danny Carroll, Mr. Decker stated that extensive training for employees has been done before child care services are transitioned to Benefind. Deloitte brought in resources and has fixed problems with Benefind. There are approximately 4,000 cases open consistently. DCBS staff answers calls about Benefind within six to ten minutes. Ms. Bell stated that she did not have the data on how many child care centers require families to pay the difference between the CCAP rate and daily rate for private pay customer, but it is allowable in Kentucky.
Animal Shelter Legislation (2017 HCR 43 – Rep. Jenkins and 2017 SCR 58 – Sen. Buford)
Kathryn M. Callahan, Kentucky State Director, The Humane Society of the United States, stated that KRS 258.195 requires the governing body of each county to employ, appoint, or contract with an animal control officer, and to establish and maintain an animal shelter. KRS 258.119 creates an Animal Control and Care Fund to be used by the Animal Control Advisory Board and establishes minimum standards in county-operated or county-contracted animal shelters. If House Concurrent Resolution 43 and Senate Concurrent Resolution 58 introduced in the 2017 Regular Session had been enacted a Shelter Oversight and Pet Overpopulation Task Force would have been established. The Task Force would have reported findings and recommendations to the Legislative Research Commission by December 1, 2017. A task force would allow stakeholders and experts an opportunity to discuss concerns and find meaningful solutions to dramatically improve conditions for unwanted animals, reduce pet overpopulation, and increase the efficiency of government services. When the recommendations come from within the group tasked with finding solutions, community members would be significantly more likely to accept the new standards and feel empowered to make positive changes.
Current state law does not authorize any entity to oversee and correct the failure of certain Kentucky county shelters to meet the statutory minimum standards and provisions for education and assistance appear to be warranted based on lack of adequate animal care. Major problems include shelter overcrowding due to pet overpopulation and lack of low cost spay/neuter programs, inadequate facility size to house all of the animals needing shelter, lack of funding to adequately staff the shelters or provide for basic animal care, poor ventilation, lack of veterinary care for animals with medical issues, unclean conditions, and inadequate training of shelter personnel. Kentucky law does not currently require animal control officers to train for such positions and the lack of training contributes to poor quality of animal care and enforcement.
Cynthia Gaskill, DVM, PhD, DABVT, University of Kentucky Veterinary Diagnostic Laboratory, stated that a 2016 study of current conditions of Kentucky county animal shelters and degree of compliance with Kentucky animal shelter laws concluded that Kentucky’s county animal shelter conditions have not been studied for over 20 years. The major goals of the 2016 study were to assess current conditions in Kentucky’s county shelters and determine the degree of compliance with Kentucky shelter laws and to determine the major problems and needs identified by shelter personnel and researchers. Data was used to determine if additional state funds or refinements and additions to current laws are warranted to ensure humane care of animals in Kentucky’s county shelters. Researchers consisted of six veterinary students who traveled to all Kentucky county animal shelters. Ninety-two county shelters were identified that service Kentucky’s 120 counties. Several regional shelters service multiple counties. Results showed that only 12 percent of counties were in compliance with all parts of Kentucky’s animal shelter laws, while over 50 percent of counties were in violation of 3 or more parts of the law.
Major problems identified by shelter personnel were lack of sufficient funding, pet overpopulation leading to crowding of shelters, insufficient workforce at the shelters, and lack of education for both shelter personnel and the public. Researchers also identified problems in including inadequate, aging, and poorly maintained facilities built with inappropriate materials that could not be properly cleaned or disinfected, poor ventilation, lack of appropriate veterinary care, and lack of appropriate quarantine areas.
The majority of Kentucky’s animal shelters are not in compliance with current animal shelter laws, and a major factor contributing to poor compliance was lack of sufficient funding for animal shelter programs. Current laws do not appear to be fully satisfactory at accomplishing the goal of providing good shelter animal care across Kentucky and need to be updated. A complete copy of the report can be found at http://uknowledge.uky.edu/gluck_reports/1/.
In response to a question by Senator Buford, Ms. Callahan stated that she attends as many of the meetings of the Animal Control Advisory Board as possible.
End of Life Care (2017 SB 243)
Senator Morgan McGarvey stated that 2017 Senate Bill 243 would have amended KRS 218A.010 to define medically necessary marijuana and amend the definition of marijuana to allow physicians to recommend, transfer, dispense, or administer certain types of cannabidiol or CBD and establish the Implementation Task Force on the Palliative and Hospice Use of Medical Marijuana that would present legislation to the 2018 General Assembly and establish issues to be discussed. The legislation was not an attempt to provide marijuana to individuals without legitimate medical problems but to take a limited approach to help individuals with medical needs. There are individuals with medical needs who will not seek relief of medical problems by using marijuana because it is currently not allowed by law in Kentucky. Kentucky should take a limited approach to allow medically necessary marijuana in limited circumstances and appoint a task force to give recommendations on how it should be implemented.
In response to a question by Senator Thomas, Senator McGarvey stated that initially only medical doctors, doctors of osteopathic medicine, and ARNPs would be able to prescribe marijuana for patients with a medical need.
In response to a question by Senator Wise, Senator McGarvey stated that the number one opposition to legalizing medical marijuana is a moral objection, but support is getting stronger because it touches so many people in a personal way. Colorado, California, Oregon, Washington, Massachusetts, Alaska, and Mississippi are among states that have legalized medicinal and recreational use of marijuana.
In response to a question by Senator Buford, Senator McGarvey stated that Kentucky could try and get a license through the federal government to have state owned hospitals handle the distribution of medical marijuana similar to Mississippi, but he does not want to wait for federal government approval. There are hurdles to overcome such as banking regulations, but the federal government is not prosecuting states who have legalized marijuana, so there are ways around the hurdles
In response to a question by Representative Jenkins, Senator McGarvey stated that 2017 Senate Bill 21, AN ACT relating to use of experimental treatments for terminal illnesses, is similar to 2017 Senate Bill 243. Kentucky already prescribes medicine without FDA approval, so why not medical marijuana.
In response to questions by Representative Wuchner, Senator McGarvey stated that he has looked at Ohio’s model. He has not had discussions with the state medical universities.
In response to questions by Representative Bentley, Senator McGarvey stated that Kentucky can create standards about who is allowed to grow marijuana, how it is grown, where it is dispensed, and how it is packaged. In the 1970s, the University of Kentucky conducted research on marijuana. Marijuana has been classified as a Schedule I drug by the federal Drug Enforcement Agency, and therefore, Kentucky has to comply with federal regulations.
Representative Moser stated that it is important to recognize that a great deal of research has been done. Pulling all the research together to understand what Kentucky is looking at scientifically is imperative. It is important that Kentucky understands what other states have done and learn from mistakes that have been made. Law enforcement has a big issue with the medical use of marijuana and an individual slipping into recreational use. Legalization of marijuana has not been standardized and regulated. Best evidence-based standards need to be created. The federal government is the biggest barrier to allow true research. Senator McGarvey stated that he has met with representatives from Hospice, the Kentucky Medical Association, and the Kentucky Hospital Association and had discussions about legalizing medical marijuana.
Consideration of Administrative Regulation 902 KAR 2:060
Laura Begin, Regulation Coordinator, Office for Policy and Budget, Cabinet for Health and Family Services, stated that the current version of the administrative regulation became effective in 2011. It requires a medical provider’s approval of a parent or guardian’s religious exemption. It effects less than two percent of children in Kentucky schools. The cabinet received complaints about having a medical entity having authority over religious exemption, requiring a health care provider’s approval and cost of a co-pay to get the form signed, and finding a provider willing to sign the religious exemption. Representatives of the Kentucky Immunization Program, Infectious Disease Branch, Division of Epidemiology and Health Planning, and Division of Maternal Health, Department for Public Health, Cabinet for Health and Family Services, the Kentucky Department of Education (KDE), and school nurses got together and worked for almost three years to come up with the amendment filed to the administrative regulation filed in January 2017. There were 141 comments received during the public comment period with half supporting one or more aspects of the administrative regulation and half opposing one or more aspects. Changes were made to the religious exemption process in the amended after comments process of the administrative regulation to clarify that the form could be obtained online and available at the Kentucky Department of Education and Cabinet for Health and Family Services’ web sites. The form needs to be completed in the presence of a notary consistent with the authorizing statute of a written sworn statement and submitted to the school upon enrollment. The new form lists all the required immunizations. Comments were received from physicians saying the immunization registry requirement was too burdensome, so the administrative regulation was changed that it would not be required until more physicians use the registry. Complaints were received from KDE about compliance this school year, so changes were made that immunizations added will be in effect for the 2018 school year. The religious exemption form was amended at the Administrative Regulations Review Subcommittee to remove references to “my child” because of fear of liability. The amendment offered at the Interim Joint Committee on Health and Welfare and Family Services would eliminate the language from the form that says I acknowledge that there are increased risks associated if exposed to this disease and to change the word vaccine to immunization.
Patty Swiney, Past President of the Kentucky Academy of Family Physicians, stated that the best way to prevent a disease is by immunizations that help stimulate a person’s own antibodies. Immunizations also prevent someone from contracting highly contagious diseases such as measles, mumps, rubella, meningitis, and small pox. A parent’s individual right to not get a child immunized based on religious beliefs stops when it will affect the welfare of the public.
Erika Calihan stated it is not about vaccines but about religious liberties afforded to parents by state law. The amended form still exceeds state law that requires a signed sworn statement to for religious exemption of vaccines, but is better than before the changes.
Representative Wuchner stated that the form, while not perfect, is an improvement. Parents who choose not to get their child immunized can be notified by school personnel if there is an outbreak of a communicable disease in the school.
A motion to amend 902 KAR 2:060 – establishes the mandatory immunization schedule for attendance at child day care centers, certified family child care homes, other licensed facilities which care for children, preschool programs, and public and private primary and secondary schools (Amended After Comments), was made by Representative Wuchner, seconded by Senator Buford, and amended by voice vote. A motion to accept 902 KAR 2:060 as amended was made by Representative Marzian, seconded by Representative Wuchner, and approved by voice vote.
There being no further business, the meeting was adjourned at 12:08 p.m.