Public Health, Welfare and Labor Committee- House & Senate
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to, if everybody can just take their seats.
We have a great agenda today for this meeting. There's a lot of information that we're going to discuss. And I'm happy that we have all the presenters that are here to present. So I think it's going to be an informative meeting. I think there's going to be actions, you know, at the end that we will be hoping to take. The biggest issue for me is what's happening with the vaping. and that will probably be the primary focus of this meeting today.
But there are some also ongoing issues that I have requested that
we have reports from DHS on. So with that, Representative Leidyman, do you have anything? Yes. Yeah, thank you. Well, glad to
Representative Jack Ladyman
Unverified
7:49
see everyone here. Glad you're here for our meeting. And I know some people have called me that are on their way around a little bit late, so some of the members may be coming in later. But one thing on the agenda, it is Ovarian Cancer Awareness Month,
so I had asked the Department of Health to bring some information on that, so we'll have that in the packet. I think that's an important subject that we need to review. So
some other important things in there, so looking forward to the meeting. So just some notes, Senator Wallace, he is out of state, working on emergency recovery in Baton Rouge, and there's some other members that are out and and then we'll have some other announcements as the items come through so at this time I will have a
consideration to adopt the August 19 minutes is there a motion and a second all those in favor say aye and opposed I have it the minutes will be adopted and we'll move to item D Arkansas Department of Health if those folks can come to the table had a good meeting last month with these folks over at the Department of Health and members of the committee we will be working to schedule a meeting at the Department of Health and take a tour of the state hospital over there and the
facilities there so look forward to that probably in the next month or so and but But right now, I think it's important for us to have this report that was issued on the Prescription Drug Monitoring Program report, and I'm happy to have Ms. Ortiz at the table and Dr. Smith. And so with that, if you will state your name for the record, then you're recognized to proceed. You just pull it down to you. That's fine. Haley Ortiz, I am the Substance Misuse
and Injury Prevention Branch Chief for the Arkansas
Speaker 21
9:43
Department of Health. I'm Dr. Rick Smith. I'm the medical director of her section at the Health Department and of
Speaker 15
9:52
the PDMP. Thank you. So just firstly, before we get
into it, just wanted to point out the two handouts that we're responsible for. First is an article by our Surgeon General, Dr. Bledsoe, and U.S. Surgeon General, Dr. Adams. In the conversation that Senator Irvin mentioned, she and Dr. Smith talked a bit about this and indicated that you folks might be interested.
So we've provided that article. I'll just note, too, Dr. Bledsoe would be willing to come and
talk further if you were interested in that as well. And just members of the committee, as a
follow-up on that article and the reason why I requested it is that there are lots of factors that are at play here with prescription drug overuse. And one of the factors, I think Dr. Bledsoe wrote this very good article about pain being a fifth indicator
and requesting that, as an indicator, actually drove up the use of prescription opioids. And so that article is a very good article. It's one he had written several years ago, but we will have him come and present. But for your information, I would ask that you would read that article. Go ahead. Great. And the
second handout we have is the Prescription Drug Monitoring Program. You'll likely hear us refer to as PDMP annual report. And Dr. Smith is going to take some time to talk through that.
Speaker 30
11:14
a moment thank you so in a highest level summary we're happy to answer questions but we wanted to review several key talking points the first is on doctor shopping a doctor shopping is as many of you know having multiple providers and in this case multiple prescribers who prescribe opioids for you doctor prescribing or
Speaker 31
11:42
doctor shop doctor shopping rather is down the state has
seen an 80 percent decrease in doctor shopping and that's on
page five of your report members thank you
Speaker 31
11:56
senator so doctor shopping is down and that's something that we think is a
Speaker 30
12:06
very good thing that you should doctor shouldn't or prescribers should try to ensure that they're the only prescriber so that the patient has one person to go to and that people can have an understanding
about what to do with these dangerous medicines. The data on drug class, which is on page eight, the total number of opioid pills has decreased by 21% since 2016, it's a very good thing. The number of stimulant pills has declined by 4.4% since 2016, stimulants are used with ADHD,
they're used with narcolepsy, and then they're also abused. So reducing that to where we have very clear diagnostic criteria and the appropriate patient to get the appropriate medicine. Opioid prescribing is on the decline, and that
Speaker 31
13:14
is on page 10, nine and 10. So you see there
Speaker 30
13:20
the opioid prescribing for multiple years.
The first one on nine is total number of opioid prescriptions. We were just visiting about this before we came in. We are down in the state, which is a good thing. We unfortunately are still at twice the national average in the number of prescriptions that we write, but we do have a decrease of 12% in opioid prescriptions in the past four years. The one that I think is very important and very telling is on page 10,
and this is the number of chronic opioid users in the state prescribed by Arkansas prescribers, And as you can see, we're trending downward. We're back to where, almost where we were in 2014. So that's a very, that's an indication of people that both need and may be addicted, because many times if you use opioids for months and months and months, you're almost certainly addicted
as well as in need of opioid medication. The county rates for opioids is on page 11. It's important to point out that this is the address of the patient, not the address of the prescriber. So this is where the people live who fill the prescriptions rather than where the prescriber, whether it be physician or nurse practitioner or PA reside. And all of our counties are above the average for the nation,
so it means we have work to do in all of our counties, but these do not necessarily represent the prescribers. If you'll, we
have a question. Do you mind taking a question as we go? Oh, sure, go ahead. I'm
Representative Jack Ladyman
Unverified
15:16
sorry. Okay, thank you, Dr. Smith. Representative Leidyman. Thank you, Madam Chair. Dr. Smith, back on page six, I had a question about the map
there where it shows data sharing? Yes, sir. Missouri, I'm from northeast Arkansas, and is there a reason we can't share with Missouri?
I mean, is their program not good? Because that does affect that part
Speaker 30
15:36
of all the northern parts. We're happy to share with Missouri. Missouri does not have a prescription drug monitoring program. They have one that has started in St. Louis County, and they're trying to expand it, but their legislature has not seen the wisdom that our General Assembly has seen in developing a prescription drug monitoring program. They're the only state in the union. Now, you could say that's good for those of us,
I'm from Northeast Arkansas too, originally it's good for us because we could move the bad prescribers across the state line and it would help a little bit. It won't cure the problem because patients across state lines all the time for medications, but that's the reason we're not doing the sharing with them.
And I'll just add that we are, we just began conversations with that one county PDMP to see if there's still the opportunity to share data. It is St. Louis County, but it actually includes a number of counties in the state, including some of the counties that border our state.
So hopefully, pretty soon, we'll be able to
start sharing with them. Thank you. And I think if you'll, you know, and back to your map on page 11, that's the prescription based on the address of the patient. It's
very likely those people could be crossing over into other
Speaker 30
16:58
states, wherever they are. And cross counties, and cross states, and cross towns, and even sometimes where they get it filled if the pharmacist is not paying attention.
and so these folks are pretty hard to track down, and there's a huge network out there of with patients about who's able, who will give you what, and they're gonna go where who will give you
Speaker 21
17:28
whatever, and that's the unfortunate situation. Yep. Okay, I have a few
more questions before we move on. Representative Boyd.
Speaker 55
17:40
Thank you, Madam Chair. Just wanted to look
Speaker 57
17:43
back on page 10, and I represent a portion of Sebastian County, Fort Smith. We're right on the border with Oklahoma, and I suspect a lot of the prescriptions are generated out of Oklahoma. How much does this change if you put Oklahoma border counties or anything? What insight can you give me about just by limiting it to Arkansas prescribers? What does it do if you change that? Thank you.
Speaker 59
18:11
I can tell you from my work at UAMS and our research group, anytime
Speaker 30
18:17
you draw a line or a border, you cause problems because you say, well, you're either to the right of the line or the left of the line, and that is a problem. Certainly, patients in your neck of the woods will cross state lines easily. Then they may come back and fill it, or they're, in our case, we'll have the residence of someone who fills it in Arkansas,
and if we have a data sharing agreement, and I'm not sure, I'm gonna look back to our administrator. Do you know the answer?
Okay, Hayley knows the answer. So data from PDMPs is compiled by what pharmacies obviously submit based on prescription. So pharmacies in this state are required to submit that data to our state PDMP. Pharmacies in other states are not required to submit data to our PDMP. They can, but it's not a requirement. And they may sometimes have limitations within their own laws about whether or not they can.
And so our data, therefore, is a bit limited. Now we, and for that reason, and for another reason as well, we do limit Arkansas prescribers to Arkansas patients within Arkansas pharmacies. And some of that is based on, you know, we want this to be valuable information that then, like, licensing boards can use as an example and identify what we can address within our own jurisdiction. But you're exactly right, and we haven't quite figured out the best way to do some of that work with our partner states.
Speaker 57
19:50
May I have one follow-up, Madam Chair? so so let me just clarify I almost hate to point this out but the when we went from 2006 to 2012 the top two pharmacies in the state of Arkansas for dispensing opioids were in my district and so wouldn't it be valuable to know you know those were being filled in Arkansas but where those generations came from and whether that whether we're still having a similar pattern of the past thank you
Speaker 30
20:21
yes I think that's I think that's correct it would be helpful it would be helpful to know what I understand that we can do is if we if we know there's a potential problem we can ask Oklahoma to share that with us specifically but it's not automatically shared so it's not routinely shared and it's not in our it's not
Speaker 31
20:42
in our control it's in Oklahoma's control but
what you're pointing out is filled in Arkansas and so we could we could do some analysis to see prescription filled in Arkansas you know well I'll leave it to the data
Speaker 30
20:58
folks but sort of what percentage are potentially out of state and from from prescribers out of state yes you're saying a prescription here the patient may or may not reside here mission may reside
Speaker 43
21:14
in Oklahoma but they're getting written by an Oklahoma physician or other prescriber but filled physically in but filled and filled in arkansas we can look
at that that's specifically those pharmacies all right thank
Senator Kim Hammer
Unverified
21:29
you and um senator hammer thank you ma'am chair on page seven uh regarding
the prescribers that are not registered with the pdmp states that between the first and second audit it appears that there's a reduction in the number of providers that are not registered with pdmp are you seeing that continuing to go down or can
you expand on that a little bit please so yes
so we're due for another um essential mandated i mean i'm sorry uh manual audit and with the first six months of 2019 so we'll we'll be working on that soon and we
We expect, based on the response from the boards, that we'll have
Speaker 30
22:12
very few, if any. With the PDMP's help, the boards have taken very aggressive action during that time. I know that some 250 of my colleagues were called to the state medical board to show cause about why there was a prescription in there and they weren't registered with the PDMP. So we
Senator Kim Hammer
Unverified
22:34
think that's really moving ahead very aggressively. And in your audit, do you identify whether or
not a prescriber is registered with the PDMP
but is not checking the PDMP? Because that's two different things. So does your audit include that? Right. So we don't have the
capability yet to do an automated audit to see that a prescriber checks before they prescribe, essentially. All we can do right now is to be sure that they have an account. Of course, if they don't have an account with a PDMP, there's no chance that they're checking before a prescription. We hope, as we continue to enhance the PDMP, that that will be available, and we will be able to run an audit to identify prescribers who are not checking the PDMP
before they, in fact, write a prescription and, therefore, would be not following the mandated use law. So the numbers in this report could change once
Senator Kim Hammer
Unverified
23:22
you get that data, is that correct? Absolutely, absolutely. All right, Madam Chair, can I have one more? You want me to go to the bottom of the queue? I'm
Speaker 82
23:29
gonna let them proceed and then I'll come back to you. Thank you. Thank
you. Go ahead, Dr. Smith. And I've got the two on the board. I'll let you have answer questions, but go ahead and proceed.
Speaker 30
23:45
So the opioid types, since 2015 the number of prescriptions and total pill
counts for each hydrocodone, tramadol, and oxycodone has decreased. So we're pleased about that. One of the things that is potentially confusing about our PDMP reports are the morphine milligram equivalents. Doctors typically don't think that way, but it's the only way that the field, I think the scientific field, knows to compare the amount of opioids between that one patient is
getting with another patient is getting or how many that a prescriber is prescribing so we use this awkward calculation from 2014 to 2018 the totally total morphine millie equivalents dispensed in Arkansas decreased by 28 percent that's on page 14 finally in terms of overdose death rates first it's not possible in our current state I mean situation not just our
our state of Arkansas, but our current situation, to attribute drug overdose deaths to prescription drugs alone, because we can't differentiate on the toxicology with the way our system of coroners is set up. So you can't say this person died because of prescription drug overdose versus illegal opioids. But the death certificates indicate that 426 Arkansas residents died from a drug overdose in 2018.
This number is an increase from 417 overdose deaths in 2017. I was just talking to Drug Director Lane before we came in. We're expecting these to begin to go down, due in part to the Narcan program that he leads, but we may not have seen the full extent of the epidemic, epidemic, especially considering that drug cartels now are, many Arkansans are easy prey
for them, and they come in and cross-sell opioids and amphetamines and various other drugs. That's our discussion so far. We're happy to answer questions. Thank you. Representative Payton. Thank
Speaker 89
26:11
you, Madam Chair. So my question is, in this report, does it include data from the VA and the prescriptions that the VA mails
out? So it includes most of the prescriptions that the VA fills at the centers,
not at the hospitals, but at their other facilities. They're not required to submit to our PDMP, but the majority of them are submitting
Speaker 31
26:38
now. Okay, thank you. Thank you, Madam Chair. Central Arkansas Veterans Health System does require all of
Speaker 30
26:44
their prescriptions, and they are submitted. I'm not sure about other VAs. I don't know about the VA health system or the Ozarks. And then, of course, with the VA, you can cross into, I think, the far northeast corner of the state goes up into Missouri
Speaker 77
27:01
for their VA benefits and to the Memphis VA. And part of that data, I think,
is being picked up on the map
where it shows prescription per address of patient because that could be a veteran that lives in that area but that's getting the prescription perhaps from the VA hospital or VA facility but that lives in that county. Can I re-cue my mic? Yeah,
Speaker 89
27:26
go ahead. Thank you, Madam Chair. So is there an effort to try to make sure that the rest get included in the future?
Speaker 30
27:34
Certainly we're happy to do that. As you know, the state laws don't govern VA facilities. So we'll take everybody that will send us their prescriptions and we'll try to work with those VAs to garner as many of them as we can. And it would be very helpful if we had
Speaker 36
27:55
that. Do we actually ask? Yes. Okay, thank you. Thank you, Madam Chair. Thank you. Representative Boyd?
Speaker 30
28:05
Nursing, the PAs come under the medical board. so anybody that can prescribe that was not registered in veterinarians and it's a little bit confusing with we've found out with veterinarians it's a bit confusing because we don't know whether Stoney is actually a dog or my son's name so it's a little it's supposed to be a joke but it's
Speaker 102
28:27
it is it is complicated with pets so just one clarification
Speaker 57
28:32
madam chair so just to clarify the other licensing boards are taking this seriously and it's not just
Yes, sir. The medical board. Yes, sir. Okay, thank
you. And to follow up with you, Representative Boyd, in the Occupational Licensing Subcommittee that we have now, that's one of the key questions that I'm going to be, we're going to be focusing on for just these different licensing entities. Are they following up and to make sure that they're calling people in saying, you need to have an account here, you need to register, you need to be doing X, Y, and Z. So we know that the State Medical Board is doing that, but that's gonna be something that we'll talk about
during that Occupational Licensing Subcommittee
Speaker 30
29:13
too. Senator, may I have one other thing? Yes. So related to Senator Hammer and Representative Boyd's questions, many large systems that use electronic medical records do ask, at least my system asks me to verify whether I've checked the PDMP or had a delegate do it because it can see this is the first time that that patient has had a prescription for opioids or benzodiazepines or stimulants,
and I have to attest to that. Now, if my hospital and my healthcare system finds me attesting to something that's not true, I'm gonna be in trouble. So there are other stop gaps in place, but not everybody, not for everybody, but for those that are practicing in large systems.
Senator Kim Hammer
Unverified
30:03
Thank you. Senator Hammer. Thank you, Madam Chair. Regarding the prescribing or the report card and the effectiveness of it,
do you have any suggestions for improvements to it that we might start to ponder
now? The prescriber comparison reports? Yes, ma'am. So I'll go into a little bit. I was gonna give a little bit of an update on that and try to answer some of your question in a bit. So yeah, so we issue quarterly prescriber comparison reports. They are given to any prescriber registered with a PDMP who also prescribed at least one opioid in the previous six months. And so the prescribers are compared with those with the same self-selected specialty within
their license group, so MDs, APRNs, PAs, and then also separately compared with all in the same specialty, no matter the license. So we've issued six so far, with the last one sent in early August, and prescribers have access to the four most recent prescriber comparison reports in their PDMP account. Then the last iteration, we sent about 7,700. So one question that we talked about, what we discussed with Senator Irvin, and we've recognized, and you may be getting at some of this as well, is that particularly in a
rural state, we have prescribers doing more than one just set specialty. So a prescriber may choose family medicine general, and that really is what they identify as, but really they have a large hospice population because they're the only ones that can provide that in that community. And so they might end up looking high compared to those others really in family general practice. So unfortunately at this time we don't have a solution to that. We continue to talk to the vendor.
This time we specifically pointed out for a rural state this is complicated. We haven't figured out a way to, whether it's issuing two prescriber comparison reports or somehow better, you know, identifying the group to a more specific place. The challenge with that is then you might have too few people to actually compare to. So what we continue to say about prescriber comparison reports is that we really think they are a valuable tool for providers. It is an opportunity to take a look at where they may lay in the state related to prescribing
But of course what we reiterate often is we don't have complete data at the PDMP. We don't have total patient count We don't have patient Information related to diagnosis, so we're trying to offer that as a learning tool as an
educational opportunity But really prescribers are the ones that are best able to describe
Senator Kim Hammer
Unverified
32:46
what's happening in their clinics Okay, and then last thing is, now we're getting a little track record as far as medical marijuana. Do you see that it's influencing the opioid situation
and the prescribers by people shifting, or can you expand or share any thoughts on that? We at the
Speaker 81
33:05
PDMP haven't done any analysis specific to that as of yet. Do we
Speaker 30
33:10
even have legislative authority to do that? I know the Health Department issues the cards,
Speaker 77
33:15
but I don't know that we have legislative authority to look at that with the PDMP, but you would know better than I.
The two systems are not connected yet. We don't know, in the PDMP, we do not know what patients have a medical marijuana card,
Speaker 77
33:31
if that's what your question is. Yeah, nor could we link them together necessarily without authority from the General Assembly. But
I think there's much interest in your question from folks who do this kind of work in the state overall, looking at how medical marijuana might have impacted the state. So I imagine that in the future there will be studies related to that, which will
use PDMP data as well. Yes, just to follow up, Senator Hammer, that's an issue that I looked at
last session. I was told because of the federal issues with medical marijuana that that would be, because
we get federal money for the PDMP, is that correct, that there was some issues there. I think that's really important that you have the ability to connect that information so that we get a more clear picture of actually what's going on.
And to your point, too, I think it's important that the program can be used on a phone or an iPad or a regular desktop system, because I know some physicians have an iPad that they're looking and using just for that purpose.
Then the issue of the drop-down subspecialty, I think it would be really helpful for providers if they, especially
if they're a home health director or a hospice director, or if they're working doing a pain clinic, their family practice specialty, but they're going
to have a higher use, obviously, if they've got a lot of cancer patients or people that are in nursing homes or hospice, obviously, or home health. So that information, I think it would just be beneficial for them to be able to kind of cue their patient population and see what's going on there.
But those are some of the issues that we had discussed. Representative Gonzalez.
Speaker 120
35:17
Thank you, Madam Chair. On page 13, you had methadone listed as one of the drugs on that list. Is it true that if you get methadone from an
Speaker 122
35:27
addiction treatment facility that that is not reported to PDMP as well? Is there anything we can
do to fix that? There isn't currently. That's based on federal law is my understanding. But the Trump administration just issued a suggested rule change which would allow some of that information from those clinics that are everyday visits
where it's just handed to the patient as opposed to being prescribed and then filled at a pharmacy, that potentially that information could be available to state PDMPs. So
I think in the future there's a good chance that that will change and that information
Speaker 31
36:06
will be incorporated in state PDMPs. At UAMS, we have one
Speaker 30
36:15
three or four in the state. The number of patients in methadone treatment is going down dramatically because of the addition of buprenorphine.
These are people that are sort of chronically addicted. Every time you get your methadone, you have to have a urine test and the methadone that they get from the methadone clinic is specifically flagged. So we see that in the urine and any other methadone gets them in trouble and gets them on the verge of being thrown out of the program. So they're pretty strict criteria for that. Go ahead. Push your button. there you go
Speaker 122
36:54
push the green button okay yeah it's on now so so the people who are in the methadone treatment program what would happen if that same person was also tested for say oxy or hydrocodone that they got from their family practice or their dealer they
Speaker 30
37:19
would they would they would be on pretty quickly on probation from the program and if they didn't clear up their urine then be thrown out of the program okay thank you
Speaker 137
37:28
okay representative Brown thank you madam chair I have two questions the the PDMP program that prescribers consult is that something that's very easy to use or do they have to search by state or can they just put in a name and a date birth and see what comes up nationally
we hope that it's it's used very easily
we hope that it's user-friendly so what happens is you enter a patient name and then if you are interested in seeing if that patient has visited other states and received prescriptions then you essentially check
a box or you can set it up where it's automatically checked depending on what states
Speaker 137
38:15
you're most interested in does that answer your question yes and just one follow-up Considering how mobile we are these
Speaker 141
38:22
days, I understand you've already addressed the state of Missouri, but what about these other states? Are they likely to join in the sharing of information?
I think eventually, yes. Oftentimes these states have specific legislation that actually prohibit them from sharing with other states. But as we move towards all states having a PDMP, at least the vast majority of states having a PDMP, and the interest in the federal government of states' data sharing, I think that we'll see some of that legislation open up and we'll be able to share with all, if not, if
Speaker 30
38:56
most. Some of the programs have built their own system. There are two general vendors in the nation.
We use one of the vendors. There's another vendor as well. And those vendors share well together or have the data interfaces to share well together. But if, say, Oregon or Washington State built their own system, they may not have an easy way to share that information with the other two major vendors. Thank
you. Thank you all so much for coming and presenting.
The last thing I was going to share about was the work with the medical board and the pain committee, if you think that. Yes, please. Sure. So we wanted to just talk a little bit about the recent collaboration in the past six months or so with the medical board, and particularly the pain committee. So as part of the PDMP law, the medical board has legislative requirement to identify parameters for triggering a report of concerning prescribers from the PDMP to the board. And so in previous years, the PDMPs issued sort of just very traditional, very straightforward
top 10 highest prescribers, or top 10 highest total MME counts, names, then submitted to the medical board for review. And we've heard pretty loudly and clearly that that just wasn't valuable to them. So we actually saw a presentation on what Ohio has done. Their PDMP is a little bit different than ours, but they essentially did a more comprehensive look at what they have termed as concerning prescribing, where they did the analysis based on a number of metrics, in their
case seven to get a more comprehensive look. So the thought was that an ED doc, as an example, may very justifiably have a high total MME count because she sees a large number of patients with acute pain and she prescribes a large number of opioids for that reason. But it may not also be appropriate for that ED doc to have a high day supply total of opioids, right? Because acute pain typically shouldn't need months of opioid treatment. So they set out to identify which prescribers
then landed in the top 5% across the board of all the metrics they laid out. We worked with the pain committee based on this analysis and have gone through a number of iterations with them and most recently gave them a list of the first six months of 2019 based on the metrics that they chose. They also requested us to double weight two of them because they thought those were really, really important to highlight. So, their seven metrics were, one, average daily dose of MME per prescription, and then
again, we're ranking based on prescribers who fall within that top 5 percentile. 5 percent, I'm sorry. Second was total MMEs prescribed, just a lump sum. The third was number of overlapping opioid and benzodiazepine prescriptions from the same prescriber. The fourth was average number of solid dosage units prescribed per opioid prescription. Excuse me. Number five was total lump sum of opioids day supply, like I mentioned in the example.
Number six was number of opioid patients total. And lastly, total number of oxycodone 30 milligram and hydromophrone 4 and 8 milligram prescriptions. Pain committee indicated that those two were very valuable at a street price, and so that could indicate misprescribing. They double-weighted the average daily dose of MME per prescription in that last one. Say the last one again. The last one was total number of oxycodone 30 milligram prescriptions
Speaker 81
42:50
plus hydromorphone 4 and 8 milligram prescriptions. Okay. Okay. Because
of the street value of them being sold.
Potentially could indicate misprescribing. Okay. And then number six was saying number six? Number six was number of opioid patients total. Okay. Patients. So
as I said, we recently compiled this data and gave a list of 20 prescribers who scored a seven or higher. And again, we stated that we had nine metrics because we had seven,
but two were double weighted. So the seven prescribers who fell, I'm sorry, not the 20 prescribers who fell within the top 5% for seven out of nine of these metrics that I just listed. And we will continue to work with them. This is the first iteration of actually getting this list. And so we'll continue to see if there are ways we can tweak, if we can add or take out a metric that might be more helpful in their analysis.
Speaker 81
43:43
And that's only with the medical board. That's not
Speaker 152
43:47
with the other licensing boards. Is that correct? Right. Right. And is there a plan?
Speaker 30
43:52
We would share them with the other boards, but the top 20 were only physicians. Correct. Okay. All
right. Any other questions? Thank you. Thank you so much. And Dr. Smith, I would love to have you come back next month or the following month on
the PANS trip that you took to Arizona. I know that Senator Hammer and I are looking forward to that. So will you come back?
Speaker 154
44:16
I will. I need to just double check my calendar, but I'll be happy to do it.
Great. Thank you. We'll slate that for the next meeting.
Thank you so much. Thank you, Ms. Ortiz. All
right. Next up. All right. Next on the agenda, we have the Department of Health. If you will come up to the table. and members we're going to start off with the item e1 i think the proclamation the governor's proclamation if you just want to mention that uh first off and then we'll go into
um Go ahead. If you'll
state your name for the record, you
Speaker 161
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may proceed. Dr. Nate Smith, Secretary of
Health. Before you start, this doesn't have anything to
do with ovarian cancer issues,
but Senator Hickey wanted me to disclose that he does have a relative who owns a company which owns vape stores. Thank you, Senator Hickey, for the disclosure.
Speaker 164
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You may proceed. Thank you. Dr. Nate Smith, Secretary of Health. Stephanie Williams,
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of Health. And Senator Irvin, thank you for inviting us. And Representative Ladyman, thank you as well.
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You wanted us to start with a discussion about the proclamation? Yes, we'll do that first. The proclamation has to do with ovarian cancer, ovarian cancer awareness month. Ovarian cancer is one of the leading causes of death from cancer, even though it's not as common as breast cancer, for example. the risk of dying is much higher because these cases are generally recognized much later in their course.
In Arkansas, we have about 200 women diagnosed with ovarian cancer each year, and about 140 die from ovarian cancer each year. Most of these are women who are older in age. The median age is 65.
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but this is a very deadly form of cancer because by the time a woman develops signs or symptoms it's usually very late. The proclamation is to help people in Arkansas to be aware and especially
women if they do have symptoms
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that are listed in the proclamation. These have to
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do with abdominal pain, early satiety, which means get full quickly after eating, sometimes changes in urination. These are all things that should be checked out rather than waiting. Unfortunately, even those mild symptoms oftentimes represent late disease.
And the risk factors that contribute to ovarian cancer?
Speaker 167
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There are a number of risk factors, the strongest of which is family history. Either family history of ovarian cancer or family history of breast cancer. The BRCA1, BRCA2 genetic tests are also significant risk factors for ovarian cancer.
So estrogen use alone or estrogen use combined with progesterone for postmenopausal hormone therapy is a slightly increased risk. And there are some actual protective factors. These include pregnancy, long-term use of oral contraceptives, and certain types of tubal ligation where the tube is actually removed also do reduce the risk of ovarian cancer.
And then hysterectomy as well. Obviously, yes. Hysterectomy if the
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ovaries are removed as well. Okay. Unfortunately, we don't have a simple, accurate screening test for ovarian cancer like we
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do, for example, for cervical cancer with the pap smear. So there's a lot of science that needs to be developed in order to better identify these cases early and help women before they develop late disease.
So if you have symptoms and you go in, what's the normal
procedure to test for ovarian cancer?
It's not a pap smear, but so what
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do they do? Do a biopsy? Generally, they would do a radiographic study, a CT scan or an ultrasound. Blood tests for
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a tumor marker, CA-125, can be helpful, but it's not a screening test, and there's a lot of false positives and false negatives.
Speaker 161
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based on results of those imaging studies, then a biopsy might be indicated. Okay.
Well, I very much appreciate the proclamation. I know that really worries. I mean, it is a silent killer, and it's something that all women, so all the men in here, to the ladies in your life, tell them about this being Ovarian Cancer Awareness Month, and yes. thank you
Representative Jack Ladyman
Unverified
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madam chair such a serious disease as this dr. Smith are you aware of any I
mean research is there a lot of research I know these are small numbers
but it's very lethal so is there research going on nationally to try to be able to identify
Speaker 164
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it sooner yes there's a lot of research
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going on nationally I I'm not a cancer expert myself but there are a number of areas of study both at trying to understand causes to reduce risk factors
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to early detection and then especially better treatment modalities and hopefully we'll
have that research right here at UAMS when we have our NCI designated cancer
institute absolutely all right thank you all right moving on to item e and if you want to have everybody come to the table um let's see i'm going to bring everybody up i'm going to bring um michael keck joe thompson and debbie jones if they'll come up
to the table so that we will be ready for a full discussion and madam chair
Speaker 180
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might i ask that we have some
and technical assistance with the PowerPoint. Dr. Smith does have a PowerPoint presentation. Okay. But the computer doesn't appear to be on. Okay, can you, thank you. Now he does have a handout as well that's titled E-Cigarette Products, Nicotine Exposure and Vaping. That should be at the top of your packet with the Department of Health banner at the top. Okay, let's get your computer working.
if everybody wants to take a seat and introduce yourself for the record while we're waiting for the computer
to work that would be great dr. Thompson dr. Joe
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Thompson president CEO of the Arkansas Center for Health Improvement
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go ahead. Dr. Debbie Jones, Superintendent of Bentonville Schools. Michael Keck, I'm
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the Government Relations Director for the American Cancer Society Cancer Action Network. All
right, great. Okay, I think they've got you up and going,
Speaker 164
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hopefully. There we go. All right. Okay. I'd like to make a few broad statements about vaping.
Speaker 167
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These are devices that are used to deliver nicotine, a variety of products out there,
from e-cigarettes to the Juul to other types of vaping products that aerosolize nicotine or other substances and allow them to be breathed in. The use among teens has really skyrocketed in the past few years, and I'll show you some data on
Speaker 170
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that in just a moment. Early data on health effects are worrisome. We do know that e-cigarettes can increase the risk of acute heart attack.
There are also concerns that particularly some of the flavoring products can cause a progressive chronic lung disease. Again, these devices have been in widespread use only for a relatively few years, although they've been on the market for about 10, so we have not yet really seen the full health effects of these products. We do know that teens who otherwise wouldn't have used cigarettes are trying these products, many of
Speaker 167
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them becoming regular users, And teens who start vaping oftentimes do go on to use combustible tobacco products like cigarettes or these small cigars.
Here's some data that were put together by Arkansas Center for Health Improvement. On the left are national numbers showing the percentage of students, grades 6 through 12, who ever used e-cigarettes. This is a little
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bit old, but you can see a dramatic rise from 2011 to 2015, and that rise has continued. On the right are Arkansas data, showing similar increases. Although the boys are more likely to be using these vaping products,
Speaker 167
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the increase amongst the girls was more rapid, and they're catching up. Up until very recently, our concerns about vaping products were expectant, concerns about long-term problems, but recently we've realized there's some very serious acute short-term problems with these products as well.
Speaker 170
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Last month, the CDC put out an advisory, and currently there are at least 450 cases in at least 33 states of severe pulmonary injury associated with vaping that has led to
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either hospitalization, intubation, and in some cases, death. And these are
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generally young people, median age, and the largest study was 19.
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In this vaping-associated respiratory illness syndrome, all patients had recently used e-cigarettes. Symptoms range has generally been fairly short, seven days, but in some
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cases much longer to several weeks. In some cases, there's also been reported use of
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THC or CBD in these vaping products, although that's not the case for all of the cases under investigation.
To date, there's no single substance or e-cigarette
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product that's been consistently associated with illness. That's an area of active study trying to understand what exactly is causing this, and there may be multiple causes and multiple syndromes that all result in a severe pulmonary
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injury. data from arkansas are are still limited as of friday we had six cases under investigation
two confirmed for probable age range was 19 to 50 four of the six were were males five of the six were hospitalized and one has required intubation they have a similar clinical presentation to those in other states present with shortness of breath, cough, in some cases chest pain as well. But also the majority of these cases also started out with GI symptoms,
gastrointestinal symptoms, nausea, vomiting, diarrhea, or abdominal pain. And when admitted to the hospital, they generally had low oxygen levels, changes on their chest x-ray or CT scan, and elevated white blood cell counts. Many of them initially are treated as if they had a pneumonia, but when they didn't get better, further studies have been done, and they've found some typical changes. Oftentimes these patients have been put on corticosteroids
and have improved. Some have improved without. In terms, I want to switch gears a little bit. When Senator Irvin asked me to speak on this, I said I would talk about some policy options that are out there to help potentially curb vaping or e-cigarette use amongst youth in particular. And I've got a number of options there, starting with T21. And I'll just move on to the next slide.
T21 is something that we've already done. When this legislative body met earlier this year, it put into law an increase in the sale of all tobacco products, including e-cigarettes, other vaping products, that will be graduated in to age 21 in 2021. This will not only reduce, hopefully, the use in the 18- to 20-year-old range, but more importantly, will help keep these devices, or at least make it harder for under-18s to get access to these products.
We know that many youth get access to e-cigarettes, other vaping products, and other tobacco products from older peers who buy it on their behalf. We expect that over time this will actually help decrease the use of vaping products. It won't be a quick solution, but will hopefully help be a sustained part of the solution. And this is just a map showing the increasing number of states and jurisdictions that have adopted similar laws.
The second I'd like to talk about is Clean Indoor Air Laws. Act 8 of 2006, the Arkansas Clean Indoor Air Act, covered combustible tobacco products, But at that time, we didn't have vaping or e-cigarettes, and so those were not included. So as it stands now, vaping devices can be used in private or public spaces unless the owners specifically restrict that use.
This leads to the sense that these products are okay, that they're normal, and adding vaping devices to other tobacco products that are prohibited from being used in indoor spaces could help to send the message that these are not safe. What I've included in the next slide is just the first page of a 2009 Attorney General opinion in which the question was specifically asked at that time,
does the Arkansas Clean Indoor Air Act regulate where these e-cigarettes are used, and are they subject to the same tax requirements of other tobacco products? And the answer given at that time was no. Now, this is 10 years ago. Our understanding of these products was very different, and just reading the first paragraph, I'm writing in response to your quest for an opinion concerning a newly marketed product called e-cigs.
You report that one manufacturer had described e-cigs as a fantastic alternative to traditional cigarettes that can be legally smoked in bars, restaurants, and the workplace. I don't think we would describe e-cigarettes quite that way today. And this may be an opinion that needs to be revisited by our current Attorney General. Taxes are another way to help regulate especially access to youth because they don't have that much money.
They are particularly sensitive to price. For combustible tobacco products, cigarettes, a 10% increase in price results in a 6% to 7% decrease in use among those under 18. Currently, vaping products are just subject to sales tax. Other tobacco products in Arkansas are taxed at a rate of 68%. So you can see vaping products are relatively discounted compared to cigarettes and other combustible tobacco products.
E-cigarettes are taxed in 15 states. seven taxed by value as a proportion of the sales price, and the other eight are relatively low taxes based on volume. And the price can also be modified by other factors like coupons, online purchases, et cetera, offered by the manufacturers. The last major policy option I wanted to talk about was flavorings. There's something like 7,000 different flavorings that are offered.
Many of them are very appealing to children, adolescents, and young adults. These flavorings have been approved by the FDA for ingestion, but they've not been deemed safe for inhalation. In fact, there are some of these compounds that we know, although they're safe to eat, they can cause progressive, irreversible lung injury. Diacetyl comes to mind, and that's present in a number of these flavorings.
Again, the flavors and their names are particularly appealing to young people. And one state, Michigan, and several cities have banned the sale of flavored products to make these less attractive to youth. And menthol is a particular concern because it tends to target the African-American community. Finally, there are ranges of options, policy options, regarding product placement and advertising.
Many youth purchases and theft are impulse buys or impulse thefts when these products are right available at the cash register. Restricting where in the stores these products are placed or advertised can have an impact. There are a number of policies nationwide to limit the placement of products within a certain distance from the cash register. Also, advertising, outside advertising, billboards, and indoor advertising can be restricted to limit the exposure of youth to those ads.
And finally, other measures that have been used or could be used include addressing web sales, web-based sales, increasing state enforcement of current tobacco purchasing laws or vaping purchasing laws, is revising the preemption rules in Act 580 of 2019, which limits the ability of local communities to put into place some of these initiatives
to protect the youth and their communities, and clarifying or tightening the oversight of vape shops. And with that, I'll go ahead and conclude. Senator Irvin, if you'd like, I can remain for questions. Yes, thank you.
We're going to let everybody present so
we can get everybody's testimony. I'm going to go to Dr. Jones.
Speaker 190
1:06:09
Debbie Jones, thank you for having me here today. I can attest to the fact that vaping is of epidemic proportions within the schools.
And this isn't just Bentonville schools, this is all schools. I had the chance to meet with other superintendents across the state last January. and we all see this rising in our school district alone we have seen a 420 percent increase since 2016 that's from our own database based upon tobacco infractions and it's not for lack of trying if you take into consideration we probably catch a fourth of these students if we're lucky
because the designers of the vapes and this type of equipment have been very strategic in creating things that are small, that are disguised like computer mice, like USB. This is an example of a jewel, which is the most common today. And it's very easy for students to sit in class and slide this up, their hoodie and vape, blowing their smoke. we've had on video where they blow their smoke into a straw in a cup and so while the all the
markets are working to disguise these from teachers and from administrators it's working it's successful yet we still see a 420 percent increase and when we look at some of the the flavorings that he mentioned i brought some for you to smell this one happens to be rainbow drops you can find cotton candy and if you smell them you'd want to try them too and so we're losing this fight within the schools and and guys this is not kids of poverty this is all kids it's very
popular and we have lost control in trying to discipline this out of the schools and we're asking that the legislature and the government officials take it seriously and act promptly because as this increases, we're seeing some devastating results. I can tell you about one a week ago Friday. A pen, much like this one, was used, but it wasn't just the nicotine within it. It's out for testing. We still don't know.
But a female shared it with three other females, and the first one to take the hit off this was unresponsive. And our nurses, thank goodness our nurses are trained in all of our high schools, our secondary schools to administer Narcan had to give two shots of Narcan to get the child to be responsive and then she was transported to the hospital. This is the tip of the iceberg. When you see the real numbers began to increase at a significant rate in 2018 and a 420% increase,
we have to act promptly in trying to
alleviate this problem. Thank you. And just, Dr. Thompson, two shots of Narcan, or Dr.
Speaker 164
1:09:22
Smith, describe that. That's a lot. That would indicate a significant opioid exposure. I would suspect probably a synthetic opioid like fentanyl would be, you generally wouldn't require that amount for a prescription opiate.
Even for a meth overdose. You could probably administer maybe one. I mean, two is significant. Well, methamphetamine is not an
Speaker 202
1:09:46
opioid, so Narcan wouldn't help with meth. That's right. Okay. Dr. Thompson? Sure. And I've got a
Speaker 206
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slide deck. I don't know, Allison, is it on here? Can I pull
Speaker 208
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it up? Mr. Secker? He has, yes. I can do that. Actually, if you'd like to switch seats, that might be easier. Okay.
i'm can imagine this is i've
heard from coaches too a lot that
their players are doing this and it's it's really causing an effect on that too i mean are you hearing from everyone across the board
Speaker 190
1:10:58
all teachers coaches the district has worked hard to educate all of our staff and they were surprised even at some of the and this is a fraction of the e-cigarettes that we've taken up we each school has thrown away probably three full bags of this last year and we start all over again but as we educated our teachers and we showed some of the
USB looking things they were surprised to learn what this is and so we also have tried some Facebook education with parents to show them some of the instruments that are used They're easily hidden all over the place. And so while we have tried education, it's
Speaker 197
1:11:42
also very difficult to catch kids with instruments. Do they set off a smoke
alarm? No. Does vaping set off smoke alarms like a cigarette might?
Speaker 190
1:11:55
For purchase, there are some systems now where you can install some vapor-like sensors within your bathrooms. Okay. but it's not your typical smoke alarm. Okay.
Speaker 220
1:12:03
So, Madam Chair, thank you for the invitation, Mr. Chair.
Speaker 222
1:12:10
I want to, while we're getting set up here, you've got three documents in front of you from our center. One is an infographic on 100 Arkansans that I'm trying to pull up here, and then a set of slides, and then an info brief that we won't go over.
But let me first just dovetail and add on to the testimony you've had so far. This is an epidemic in our schools. The updated information that we're going to try to put up here is 44% of Arkansas high school seniors now report that they have vaped at some point in their life. 20% do so on a regular basis. I have said before and I will say again, lighting anything on fire or vaporizing anything and breathing it into your lungs
Speaker 224
1:12:52
is not healthy. And let me go there. In your lungs, which are the most sensitive organ in your body next to your brain, you have an air sac and you have a blood vessel.
there's one cell between them and if you're breathing stuff in and coding that cell you're gonna have long-term problems with
Speaker 222
1:13:11
oxygen coming in and carbon dioxide coming out this is the infographic that I mentioned we'll make this available I've met also with some of the school nurses they echo actually amplify the testimony of dr. Jones this is this is going to become the next generation of oxygen dependent children that we have and I think we'll see
Speaker 224
1:13:29
that sometime for 25 and 30 years of age let me go to my slides now if I can I think
they went to get somebody from wish we would have somebody from tech be at all committee meetings for
Speaker 188
1:13:51
this purpose you've got slides in front of you a copy that
Speaker 222
1:13:54
I'll just go forward this starts with federal action on e-cigarettes I wanted to be able to give you what the federal action is on e-cigarettes unlike tobacco which has been around since before our nation was formed. This is a new product and these products and technologies are outpacing our policies and our abilities to control them. The federal Smoking Prevention and Control
Act of 2009 gave the Food and Drug Administration the authority to regulate tobacco products and within that it had a deeming clause that gave the FDA the option to extend regulatory reach to any tobacco product that it deemed to be within its authority. In May of 16, just three years ago, the FDA extended that authority under the deeming clause to regulate electronic nicotine delivery systems or ENDS. These are vapes, vaporizers, vape pens, e-cigarettes, and so forth. And as Dr. Jones mentioned, it looks just like a USB port. This is a vape.
Speaker 224
1:14:48
This is a pod. This has as much nicotine in it as a full pack of cigarettes. You You push this into the vape effort, and you smoke it just like a cigarette. So if anybody wants to see it or try it, feel free to afterwards, I'll not demonstrate it for you here. The FDA regulation on e-cigarettes, and the regulation, that's it, okay, there we go.
Keep on going. We're on the next one. While that's coming up, if the FDA says Juul is saying that they are a smoking cessation product, if the FDA does deem it to be a smoking cessation product, does that mean that insurance will cover it like they do
Speaker 233
1:15:41
the patch? It would depend on the U.S. Preventive Services Task Force determination or voluntary determination by
Speaker 222
1:15:47
the insurance company. A and B level prevention services by the task force are required. other decisions are optional for the insurance company I'll come back to your
Speaker 236
1:15:55
question in a second because there's some breaking
news today that may inform that okay and then back to dr. Jones's point the the flavorings are approved by the FDA as a flavoring but not necessarily in conjunction with a vape pin is that correct at present the flavorings are not
Speaker 222
1:16:16
under the jurisdiction and in fact in action your legislature took in the last session there's no oversight body now for liquids that are mixed in the state of
Arkansas for addition okay okay go ahead so the FDA regulates the manufacturer the import the packaging the labeling the advertising of the end product itself it includes components but excludes the accessories that's where the liquid piece comes into. Beginning in 2018, all covered products must have the required nicotine is an addictive drug. Nicotine is as addictive as cocaine and therefore that's the target for the companies is to get youth addicted so
that they become lifelong consumers. And the vape shops may end up being both retailers selling and manufacturers if they are manufacturing the e-liquid itself that goes into the product. So far the discussion has been largely about them being a retailer, but they actually have the potential to also be classified as a manufacturer. In the advertising restrictions for traditional tobacco products are very different from the ENDS products. You had a tobacco control act in the 70s, but much of the restriction was because of
Speaker 224
1:17:33
the master settlement agreement through lawsuits that the tobacco companies agreed to not advertise to school
Speaker 222
1:17:40
or in front of schools and other restrictions. Just for your information, it was just 2003 that the major magazines supplying magazines to our library ceased to have print tobacco products in their advertising to youth within our library system. Those restrictions are not true for e-cigarettes. In fact, this is an ad targeting our youth from 2015.
The Food and Drug Administration acted on ads such as this with a warning to Juul for advertising to youth. Of course, what we see, those of us that are reading the newspaper or watching old cable television, we see the advertisements
Speaker 224
1:18:19
about how it's a smoking cessation product. Meanwhile, the companies have been in the schools, they've been around the schools, and they've been on the Internet targeting the youth with advertisements
Speaker 222
1:18:30
like this. Some of the restrictions that are not in place for vaping, that are in place for tobacco, is advertising in front of schools.
This is actually a store right in front of Mount St. Mary's here in Little Rock, and you can see the neon signs of Juul there facing the front steps of Mount St. Mary's. This is true across our state, in and around our schools. Let me conclude there. I would say this body, in 2015, Nate mentioned the preemption law. You took away, or your predecessors took away, the authority of any local community to restrict the advertising, the marketing, the sale of vape products.
So the responsibility for the safety of our youth solely rests with you. No local municipality can take an action at this point in time. Thank you very much. Be glad to take
Speaker 241
1:19:25
questions at the end. Thank you. Mr. Keck. Thank you, Madam Chair. I appreciate the opportunity to be here today, and I will simply echo the comments that have been made by the Secretary, by Dr. Thompson, and by Dr. Jones. I am extremely nervous being this close to an educational administration official.
I am having flashbacks from my years growing up. I probably would have spent a lot of time in her office. This epidemic that we are facing today, I think there are a number of steps that we can take as a state. that we can work together on and we can take advantage of the opportunities that have been put in place by actions taken by other states across the country other states have prohibited e-cigarette use the same as other tobacco products we could update our clean indoor air act to do that some
municipalities and one state has banned flavored e-cigarettes and e-juices I I think we should consider doing that as well I think we need to consider and look at implementing the same restrictions on e-cigarettes as we have on tobacco in regards to sales and marketing and I think we need to be especially mindful of those products that are promoted out of compliance with FDA as being cessation or healthy products I think we should look at e
cigarettes from the component that they should be included and regulated the same way as tobacco is. We made the decision this last year, the legislature did, to move that out of the ATC. That provides this legislature now going forward an opportunity to find the right location for that oversight. We'll leave to your collective wisdom as to figuring out where that needs to be but currently the safety
provisions such as for workplace safety child proof safety and and other things were all eliminated in act 1071 and i would encourage this body to look at the preemption law to be modified that instead of establishing a ceiling that we establish a floor that we establish a standard for the state and allow some flexibility for municipalities to meet the needs in their communities e-cigarettes have been and vaping products have been taxed a number of different
ways that was mentioned earlier by the secretary percent of wholesale has been done from one end of the country to the other from a percent of hotel 15 percent of wholesale to 92 percent of wholesale the state of new york has implemented a special retail tax as has the state of new mexico some states have implemented a per milliliter tax going from five cents per milliliter to 10 cents per milliliter the state of illinois has allowed cook county and the city of chicago to not only
assess a per milliliter tax but also a tax on each device just a
minute members i'm sorry if you'd like to have conversations you can take them out into the back thank
Speaker 241
1:22:40
you please proceed thank you And lastly, the state of Connecticut has implemented a combination of per milliliter as well as percent of wholesale, which they are currently the only state in the country that does it that way. I mention all of these things to tell you that there are options available to you, and
it is my strongest encouragement to you to take action. Our organization and others will be a resource for you to assist however we can. Thank you. Thank you. Madam Chair, if I
Speaker 222
1:23:13
could add, I forgot my bombshell. The Food and Drug Administration today issued a warning to Juul to cease all advertising as a product that has less harm than tobacco. They gave them 15 days to respond. Juul has not been approved as a modified risk product by the Food and Drug Administration, although they have been out and advertising themselves as such.
So now the FDA is in alignment with the CDC to recommend no use of e-cigarettes until their further study.
No use of e-cigarettes until they are further studied for all age groups. Is
Speaker 233
1:23:46
that correct? Well, the CDC is for youth, pregnant women, any adult who has
Speaker 222
1:23:52
not smoked before, and they are somewhat equivocal on those that are on two or three packs a day
Speaker 167
1:23:59
of cigarettes. Nate, you may want to add to that. The recent CDC warnings about the severe pulmonary syndrome,
they've recommended not to use e-cigarettes at all for any age group until more is understood. But the Food
Speaker 222
1:24:15
and Drug Administration today issued a specific warning to Juul about effectively falsely advertising without
authority. Gotcha. Okay, thank you. Before I go to questions, I'm going to go to Senator Hendren. Senator Hendren, you're recognized to present. We have an interim study proposal on this issue, So you've heard the information, members.
We will take questions here in just a minute. But we will be filing at the end of this meeting an interim study. Senator Hendren. Well, thank you, Madam
Senator Jim Hendren
Unverified
1:24:50
Chairman, and thank you, members of the Public Health Committee, for allowing us to bring this information and request for an interim study. Those of you remember that in our last session, I had a little bill, Senate Bill 571, regarding taxation of vaping products
and also cigarette and nicotine, other nicotine products. We passed it out of the Senate and sent it down there to you guys in the House and you did what you'd like to do with my bills and I never saw it again. But I think the purpose of this hearing, though, is for us to try to start coming up with a plan that we can take some action in preparation for either a special session or the fiscal session or, worst case, wait until the general session in 2021. I'll have some questions for Superintendent Jones and I appreciate her coming from Bentonville
I've heard her testimony before and what is the most disturbing to me and she came to many of our forums during the session time and time again to voice and other superintendents did as well they're concerned that this is becoming has become an epidemic in schools and what's especially troubling to me is when I heard testimony from her and others about the addictive nature of this product where kids, even though they know they're going to get in trouble because they are so addicted to the product and can't stop, continue to do it and suffer the consequences of the
discipline that comes in the schools. So adults and kids are in a different category. We look about our oversight responsibility on individual choice and freedoms. Allowing a corporation to misadvertise what their product does that is addicting kids is an appropriate role it's time for the legislature to step in and show some oversight now the reason that this interim study is just about vaping whereas the bill also included other cigarette taxes and so on is because in order for us to know what
type of taxes should be assessed to vaping I think we need to know what the what the health consequences are. We have a good idea of what the health consequences are for cigarettes because it's taken us 50 years, but we finally figured out it's pretty, pretty doggone expensive for the people and for the taxpayers. And I will be filing an interim study for cigarette use and the costs and how we rebalance those, that tax load to the people who are causing the cost. But with regard to vaping, the three things that I hope this interim
study will accomplish. The first one is, it seems like every day there's more data coming out on what the long-term consequences of vaping are. Just since our session, we hear reports of sicknesses in Arkansas. We hear of a death. We hear of incredible lung issues that people are having. So as a body, we need to sort through, with the help of some experts, what are the long-term consequences? In cigarettes, we thought it was fine for 20 or 30 years, and only after everybody started getting lung cancer did we figure out that yeah that was probably not the
best idea for relaxation uh the next thing is how do we curve youth vaping what what can we do and we heard some suggestions today moving it further away from schools giving more authority to communities or to school districts but what troubles me is you know we increase the age from 18 to 21 well it's already illegal at 18 and we have what 14 year olds doing it 13 year olds doing it so we've got third graders i mean clearly we've got changing the age limitation is the right thing to do but we've got to do much more if we're going to stop it from becoming an
epidemic and an entire new generation becoming addicted and then the final thing just like i've asked for the information from dr thompson and others on cigarette use is what's the cost to the taxpayers if adults want to vape that's their choice but they shouldn't ask people who don't to pay the cost, the healthcare costs associated with that. So in order for us to make that taxation decision, we need to know what those healthcare costs are. So that's what I hope we can determine through this study. And again, I appreciate Senator Irvin allowing this
to partner with me to get this interim study going through this committee, because I know that you all address public health issues like this all the time. And I hope that you can help us find the answers to these questions so we can come together with a bill from both the House and the Senate that we can stop some of the stuff we heard about going on in Bentonville
and in all of our schools. Thank you. Thank you. So that will be, that interim study will be filed at the close of this meeting, and then we'll ask for a formal adoption at the next meeting by the members of the committee. And I'd like to keep it in here just because I think it's a topic everybody's interested in.
We're all hearing from our school administrators about this and what's going on. And another big
concern is adults that have the vaping e-cigs and the JUULs, kids are kids. Quite often you see in emergency rooms you will have a child who will accidentally get into their mom's
purse or dad's purse or somewhere in the car, and they accidentally overdose on prescription medication.
are we doing anything to track whether a child is you know that's easy thing for a child to pull out and start using i know it's relatively early but i would think that's something that we would try to track as well if that's happening because i do know that some
schools have confiscated these particular devices from children children as young
Speaker 166
1:30:28
as third grade yes the Arkansas poison control centers had so far this year 80 cases of toxicity
Speaker 167
1:30:37
related to these products and we work with them to track and monitor those okay
good okay I will go to questions now Senator Garner I believe thank you Madam Chair, and I
Senator Trent Garner
Unverified
1:30:50
have multiple questions. Would you prefer to handle it? Just ask a
question and get back in the queue. Thank you. So on the recent health issues that have been tied to vaping and e-cigarettes, it seems to me that the vast majority of these cases are health issues and deaths associated with vaping. It's attributed to people using either illegal THC-related products
or black market cannabis or illegal drugs, often bought off the streets or from actual drug dealers. For example, out of the five deaths that have been attributed to vaping products, Two have been directly related to THC-related products. One is highly likely to be related to THC product. Similarly, a study among patients in Illinois and in Wisconsin found that 83% of the people admitted for these kind of diseases and issues have admitted to using THC-related products, which have been bought off the black market. Another study in the New England Journal of Medicine focused on 53 patients.
They found that 80% of those had used cannabis-related products. 7% have used CBD, oil, and 17% said they use nicotine or vape nicotine only. Even Dr. Jones, as she was describing her testimony earlier about that terrible case, admitted to an illegal drug usage, I believe opioid fentanyl most likely, even though I believe you said the testing hasn't confirmed it yet. My question is, under your policy considerations, you didn't list anything dealing with the either illegal black market sale of oils or vaping products.
And conversely, if we increase regulation and taxation on the legal means of getting vaping products, is there a concern within either one of your departments that that would drive to the black market, which we know has a correlation between severe health risk?
Speaker 164
1:32:34
Thank you. I'd like to tackle at least some of those questions. That is true, that there's limited data at this point, but about 80% of the cases have also reported
Speaker 167
1:32:47
either exclusive THC or combined THC and nicotine use for these severe...
Senator Trent Garner
Unverified
1:32:53
And that would be illegal unless you got it from a explicit place, correct? Right. In
Speaker 170
1:33:02
some states, you know, those products are legally sold, but in many cases, it would be illicit. Now, that's not all the cases, And about a third of youth who use vaping products will use both nicotine and THC products.
So how many of these cases are due to those illicit products and how many aren't is not clear at this point. That's still being studied. Now, the issue of whether banning the sale of legal product would drive people to illegal product, that seems to be unlikely for two main reasons. One is the devices are what we would be limiting the sale of.
And as far as I know, there's not a huge market for illegal devices just for the e-juice and the stuff that goes into them. And second, a lot of people are already using a mixture of both commercially available and then so-called street products as well. So we don't have evidence at this point that decreasing access to legal products would drive people to illegal products
because what they're using is primarily drugs that are illegal anyhow. And what I
Speaker 269
1:34:33
would just add is I think we will find that it's not
Speaker 222
1:34:38
a single compound that is causing this. It's the process itself of vaporizing materials and bringing that into your lungs. So by controlling the vaporizer itself,
Speaker 233
1:34:48
then the other issues become still available
but not deliverable. Yeah, and THC is legal in certain states.
Is that correct? So you could travel or somebody could go and bring it. They could purchase it legally and bring it across state lines illegally, but that's probably how that's happening. But CBD oil, or CBD, that can be sold, correct? So do we have currently, can
vape pens and e-cigs be sold at medical marijuana dispensaries? Do we know?
Speaker 164
1:35:29
I'm not sure if those either are being sold or are legally being sold. There's
Speaker 166
1:35:35
nothing necessarily that says that they can't sell
them. I'm just saying the combination of the two is... I
haven't been, but I'm not aware
of any restrictions. Okay. The combination of the two is what we're discussing with Senator Garner's question.
Speaker 275
1:35:52
So I think... And people are using these vape
Speaker 170
1:35:56
pens and other things to aerosolize a whole variety of substances
that were never intended to be vaporized as well. So something may be sold for one purpose, but then vaporized. Senator Garner? Yes, ma'am. I have another question. Go ahead. Thank you.
Senator Trent Garner
Unverified
1:36:17
Smoke and cessation. So it seems like from
the testimony I derived from the experts that you do not think this is a bona fide use as a smoke and cessation product, that traditional tobacco products. I'd like to know why the Public Health of England, which maintains that vaping is 95%
less harmful than tobacco, the Royal College of Physicians, which represents 36,000 doctors across the world, advocated in the nicotine without smoke, tobacco harm reduction, e-cigarettes appear to be effective when used by smokers as an aid to quit smoking. However, the hazard of health arise from long-term vapor inhalation from e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco. Anecdotally, when Senate Bill 571 was debated this last session, I received literally hundreds
emails from people in Arkansas who said they use vaping related project products legally to help them either quit or dramatically reduce their smoking I'll give you example of mr. John Fritz six years ago my wife and I were introduced to vaping as a way to quit smoking by our friends we struggled for several years to quit especially as a parent of two children we tried gums patches cold turkey none of it helped since we quit smoking and started vaping our quality life has increased we are no longer tired all the time no longer have a call for experience constant
health issues we are healthy even our doctor has told us that the changes that switched to vaping has made our health better we've lost weight now this is an arkansan and i've had hundreds of emails i've had dozens conversations for people is it the position of you experts on this board on this panel today that there is no smoking cessation benefits to using these kind of products for the adult population we're not talking about children at now i think that's a separate issue
and i'll agree with a lot of testimonies to happen today but specifically why are these people wrong thank
Speaker 170
1:38:20
you i'm i'm happy to tackle that first but um i'm sure others here have many things to add I think some of those opinions that you just read or
Speaker 164
1:38:30
indicated might have been reasonable 10 years ago, but I don't think that those are sustainable
Senator Trent Garner
Unverified
1:38:35
today. One was in 2016, one was in 2018, those opinions.
Speaker 164
1:38:39
Yes, I don't think that those are current based on our experience so far.
Speaker 170
1:38:45
None of these products have been approved by the FDA for smoking cessation. In fact, there's a lot of reasons to think they wouldn't be very effective. they give a rapid hit of nicotine, and that tends to reinforce addiction rather than reduce addiction, as opposed to the gums and lozenges and patches, which give a more sustained delivery. We
Speaker 164
1:39:07
also know that these products, for example, just the nicotine itself can increase the risk of acute myocardial infarction.
Now, if you're comparing it to cigarettes, the risk of that is less. But today, where
Speaker 170
1:39:22
we have 450-plus individuals under investigation for being hospitalized for acute pulmonary injury, I don't think any expert in the field today would recommend responsibly that someone vape as of today. We don't have that kind of thing happening from cigarette products. People die from cigarettes every day, but they don't develop an acute pulmonary syndrome that lands them in the hospital
and may be dead. So I would say that as of today, I could not recommend any of my patients use a vaping product regardless of their age, regardless of other
Speaker 161
1:40:01
particulars. To build on Dr. Smith's comments, I
Speaker 223
1:40:05
think the emerging information that we don't know
Speaker 222
1:40:08
why these individuals are getting ill today causes one to have caution about making a recommendation and move to those. I will not differ, but modify a little bit. If I had a two to three pack a day, 60, 55-year-old smoker, a month ago, I might have thought about suggesting that they use a vape product.
But it would be under the oversight of a counselor or a physician with accountability for stepping down on the nicotine levels that they're consuming each day to get off the nicotine. These devices deliver more nicotine than cigarettes. So you can easily become even more addicted to nicotine by using the vaping products if you don't have an accountability mechanism in place to assure that you're stepping down and moving away from your addiction. But today I would not recommend anyone's change until we have more information.
Well, I think that, you know, losing weight, I mean, everybody knows if you, you know,
sometimes that is a, smoking cigarettes is something that people use to lose weight. so that's not necessarily a good thing to lose weight. But, I mean, moving on, I think it's important to note that there has been some news breaking that has changed this landscape. I mean, obviously a 420% increase from 2018, correct? So that's within one year. That's a huge rise in just the usage amongst children and teenagers.
um representative gonzalez thank you madam chair um my
Speaker 120
1:41:41
question was on the the kids use mainly in schools is there are you seeing
Speaker 122
1:41:47
an overall use use in tobacco products rise or is it just the vape products it is
Speaker 220
1:41:54
almost exclusively vape products now and that rise was since 2016 so there's no
Speaker 124
1:41:59
reduction in traditional tobacco smoking we don't see tobacco
Speaker 220
1:42:03
products we see vape products now students that have not been smokers before take
Speaker 190
1:42:09
this up for the first time
and one of those little pods has a nicotine of a whole pack of cigarettes and
Speaker 220
1:42:16
so the addiction comes from this they begin and get addicted to the vaping
Speaker 124
1:42:22
okay so so you're not seeing the use of traditional smoking products like you were but vaping is essentially no
Speaker 220
1:42:29
um juveniles have made transition to vaping and also
Speaker 122
1:42:32
on this on this slide from 2015 to 2016 it seems like there was a pretty sharp reduction and then it started to climb what caused
Speaker 223
1:42:41
that reduction at that time I can't explain that reduction but I think we have a consistent trend in place that's
Speaker 55
1:42:54
going on the upward trend now thank you represent Boyd thank you madam chair I have two unrelated questions you want
Speaker 57
1:43:00
me Can you try to ask both or just? Go for it, just go. Okay, so number one is it sounds like either, the implication is you think it's either a chemical or the process of vaping itself that is leading to these pulmonary issues. I guess just curiosity, what leads you to believe that
and it's not some random infectious agent that's
Speaker 164
1:43:20
hard to identify? I'll go ahead and tackle that. As an infectious disease physician, these patients have been investigated extensively for evidence of an infectious
Speaker 170
1:43:30
disease pathogen, and none have been found. The specimens that have been taken, they call bronchoalveolar lavage, done by bronchoscopy, have not demonstrated any pathogens, but they have shown patterns that could be consistent
or would be consistent with inflammation due to a chemical. And when Dr. Thompson talked about the process of vaping, that process of vaping can generate or produce chemicals that are breathed into the lung, and then they can cause irritation. And
Speaker 222
1:44:06
because, and it's, I mean, these are fast-moving, you know, studies, not even studies, just reports. In the x-rays that had been reported, there are four different ways this presents,
four different timelines, sometimes it's acute, sometimes it comes in over several weeks, which leads me to believe that it's not a single substance and a single disease. It's a complex exposure, and we're seeing people react in different ways and present in their lungs because that's what's been exposed with different types of illness. Okay.
Speaker 57
1:44:38
Thank you. That's what I wanted to confirm. So the next thing, just, you know, I want to clarify. I do agree we need some legislation.
I won't be real specific on what that is, but there are some areas where I agree there's legislation necessary but I just want to make sure that we don't forget about education because it tends to be easier to legislate than educate and so I just want to make sure that you have some kind of hear confirmation you have some kind of plan to have a public campaign educate health care providers kids in schools what is going to happen even if it's not about vaping nicotine itself Dr. Smith you've indicated you go back to and say look really think hard about what you're doing thank you i would just point
Speaker 241
1:45:24
out that in our efforts to get people to stop smoking tobacco for every dollar that we spend to educate people and encourage them and provide cessation services the tobacco industry is spending 14 to get people to smoke so i think you're representative boyd you're absolutely right we have to have a strong educational component at this working with parents working with administrators and teachers coaches but but really what we have to do i think that is a component of it but that's not the sole answer to this and i appreciate you bringing it up
Speaker 269
1:45:57
and i would just add and ask for each of you in your public
Speaker 222
1:46:02
speaking opportunities and your communications ask every parent to talk to their child if 44 of high school seniors in this state have used an e-cigarette and one in five are regular users your kids their friends the people you're having over at your house are in that group and education has to start with parents and children first and that's why i went and bought one of these so i could show every parent what it looks like so they know what to look for because it looks just like a usb port that you would stick
into your computer and download your homework uh and so you know i really do encourage each of you to make part of your amplification of this message. It is an epidemic. It is risky. Kids shouldn't have it. Let's do what we can to
Speaker 164
1:46:48
educate in every possible way that we have. Representative Boyd, I also agree with your point. A product that is putting people in
Speaker 170
1:46:55
the hospital and even killing them is not one that we should actually have to regulate. People ought to know not to buy and use it. But the Health Department has been and continues to have a pretty comprehensive program for educating public and various different audiences on the risks of tobacco products, including vaping.
And Chief of Staff Stephanie Williams is prepared to talk a little bit about the things that we are doing and what we have planned. Chairman Irvin, I'll leave it to you whether you would like to take a few moments to hear that. Yes,
we will. But before we get off that, I do think it's important that people understand the organ and how the organ of the lung is incredibly sensitive. And I'm glad that Dr. Thompson said that because when you understand the anatomy and physiology of the human body and particularly of the lung
and the delicacy of how it processes oxygen and carbon dioxide, it is a no-brainer that you should not inhale anything other than oxygen I mean it should just be an automatic thing that we but because of social media because of advertising because of flavorings because of peer pressure it's become the cool thing and and and people aren't questioning it and I've actually had parents that have said to me you cannot fight this because their son
was basically bullied that said if you tell you know anybody that you have a jewel or that we have a jewel we'll beat you up and that was a true story from a friend of mine who is a mother who is just beside herself because of what's going on in the school system so I mean it is a rapid hit I mean, it's a rapid hit, it's a rapid high, it's something that you can, I mean, from their reports, I have not personally tried this, but, you know, I am taken back by how
it has been marketed, and I think that, for me, is the biggest cause for concern. Now, if you are an adult smoker and you are trying to get off smoking and cigarettes, that's one thing um but again i think there's a lot of concern here um i'm gonna go to more questions and then we'll come back to you if that's okay representative miller thank you madam chair
Representative Josh Miller
Unverified
1:49:28
uh dr smith i understand what y'all are saying dr thompson you have a lot of respect for
you i don't think the the problem i'm having as a legislator as a parent i agree 100 with what you're saying i've got a 17 year old he's got friends at vape uh and and he may have tried it himself and i hope not and i've talked to him about it and if i ever catch him doing it i'm gonna kick his butt but because it's stupid but my problem is this it seems like we're constantly being asked to legislate behavior and to legislate parenting, more or less.
And here's, what is, Ms. Smith, what is the, I mean, I know, and this may seem goofy, car accidents cause a lot of deaths in Arkansas teenagers. what's your department doing about that? How much are we diving into that? Also, STDs. Cause a lot of deaths. Cause some associated healthcare costs.
How much is the health department spending on that? And what are we doing? And I'm, hey, again, there's no debate about whether or not vaping is a healthy choice. But I don't know. I mean, I just feel like we're being asked to step in and take on the role of a parent, and we're not parents. We're legislators. Could you address what I've said, please? Thank you. Thank you. These are excellent points.
Speaker 164
1:51:20
And we do have programs to address motor vehicle injuries, especially amongst youth, and we also have many programs to reduce sexually transmitted infections. So these are all key public health issues. Fortunately, in both those cases, the number of deaths due to both of those have decreased with focused efforts and in many cases
Speaker 170
1:51:49
it's education, but also laws, seatbelt laws, speed limits, those all legislate behavior.
In fact, I would say probably most of the laws that you pass affect human behavior in some way. And these have all been important in addition to education and programs in reducing the number of Arkansans who die from these various causes. So I applaud you for the work that you've done over the years, you and your predecessors. And unfortunately, there's still work to be done. That's why you're here. That's why we're here. Can I
Speaker 166
1:52:22
have a quick follow-up, Madam Chair? Yes, sir.
Representative Josh Miller
Unverified
1:52:26
Thank you. And I appreciate that. I really do. And I'm not trying to seem disrespectful, but are we on either of those other two topics, sexually transmitted diseases, car accidents, have we or has the legislature been asked, and furthermore, has the legislature raised taxes to fund those programs?
Speaker 164
1:52:56
The tobacco excise tax helps to fund our
Speaker 170
1:53:03
Arkansas trauma system and injury prevention programs which address the issue of motor vehicle accidents. We have programs for sexually transmitted infections that are funded in part by federal dollars, and also leveraging state funds as well.
If there was an easy fix for eliminating the risk of sexually transmitted infections that didn't involve changes in sexual activity, then I'd be all over that, but unfortunately there's not. Representative Miller,
Speaker 222
1:53:44
let me give you just a concrete example to your question. There's no question. Your policies are only one aspect of the solution, but when this General Assembly passed the graduated driver's license law that required a stepped graduation into free and open driving
of youth, you dropped the mortality rate for teens in this state by 50% in 18 months. You had 50% fewer knocks on
Speaker 233
1:54:10
the door because you didn't allow 15 and 16 year olds to be out joyriding five in
Speaker 222
1:54:16
a car at 3 a.m. You dropped the mortality rate by 50% in 18 months. Now parent education was part of that, but you gave the parents a backup to say, no, you can't go out at midnight. You got to be in because it's against the law. And so this is how your policy and that education work hand in hand. And I hope you can find an agreed
upon, you know, floor for the state to take on this product. But regardless, I would encourage you to return to local control so that those local elected officials that are closer to the teachers, that are closer to the parents, can actually experiment with things and let us know what works. And then they can lift that up and you can take that on as a statewide policy. Thank you. Thank you.
Senator Kim Hammer
Unverified
1:55:05
Senator Hammer. Thank you, Madam Chair. A couple thoughts on the, if I remember right, based on your testimony, the whole idea of
the vaping product was to be a safe alternative to smoking and that's the
way the industry presented it. Is that correct? That
Speaker 233
1:55:23
is how they submitted it to the Food and Drug Administration for approval. It has not yet been
Speaker 222
1:55:29
approved by the FDA as a modified risk tobacco product and that's what today the FDA cited Juul specifically and gave them 15 days to respond or cease all advertising in that manner. So would it be just, and it's late in the day, so if
Senator Kim Hammer
Unverified
1:55:44
this is a bad idea, tell me,
but if that was the pretense for why they wanted to introduce it in the first place, why couldn't we require that it requires a script, like a nicotine patch, in order to be able to get access to it if their whole pretense on the front end was this is a safe alternative to smoking in order to choke this thing down? You're
Speaker 188
1:56:07
articulating my original effort to kind of keep this contained because if it's on the
Speaker 222
1:56:12
path to withdrawal, you're going to have to have somebody measuring how much nicotine you're doing on a daily basis as you step down.
And there's going to be problems from that. There are going to be, you know, setbacks. There may be side effects. It could be, but that would be a pretty big step in the FDA's purview to make it be a class drug, if you will. There is no benefit from nicotine. There is no medical benefit from nicotine. You can't overdose on nicotine because there's no appropriate dose of nicotine. So this is actually not a drug. It's a delivery product
Speaker 254
1:56:46
that the Food and Drug Administration is actually regulating. Follow-up, Madam Chair?
Senator Kim Hammer
Unverified
1:56:51
Yes. And so with the news coming out today and everything that's playing out from what this was originally tended to be and how it's being abused, and I'm going to use the term false advertising, Have we seen the AG or other AGs' discussion about going after them for the basis of false advertising? This would be patterned after, like, the tobacco settlement money. I think it's happening too fast.
Speaker 222
1:57:17
I think this is, again, where the technology and the products have gotten ahead of our policy.
The FDA has approved this as a product. They have not approved, nor have they disproved, that it's a tobacco risk reduction product. So it's still in the application and
Speaker 241
1:57:37
review process. Now, Mike, you may have. Senator, the state of North Carolina has announced their intent to file litigation against eight e-cigarette companies for their marketing and promotion of their products to students under the age of 18, young people under the age of 18.
And I would add, too, it's not just the flavors. There are
also Juul skins. So you can pull that up, and these are completely targeted to youth. I mean, if you look through them, these are targeting, these jewel skins are targeting really a lot to youth, but, I mean, all kinds. So it's
not just the flavoring, it's the packaging, the delivery of it. And I would just
Speaker 222
1:58:26
add, the tobacco litigation took a decade.
I mean, we'll lose a generation of kids if there's not effort put in place to actually address this head on Thank you, Madam Chair.
Speaker 120
1:58:40
Thank you. Representative Gonzalez Thank you, Madam Chair. I'd like to say for the record, I'm all for Stopping the marketing of
Speaker 122
1:58:45
this to children. I would like to see us do what we can to keep it out of the hands of kids But for adults, I think, you know, they can make their own own decisions My question is Some of these products are FDA regulated. Some of these are black market products out of all the deaths and sicknesses that are acute
sicknesses do we know that they have come from FDA approved products or from
Speaker 164
1:59:10
black market we know that they're being delivered through these commercial products now what's being
Speaker 274
1:59:16
delivered you don't know what they're putting in them can can
Speaker 122
1:59:21
be a wide variety of things so you can't really contribute it to the vape
Speaker 164
1:59:27
products that are being we know some of these cases have have also used non-commercially prepared products but that's that's not true of all cases okay
Speaker 120
1:59:37
do we know how the illnesses associated with vape products compared to hospitalizations
Speaker 122
1:59:43
and illnesses with traditional tobacco products well these these cases
Speaker 167
1:59:49
of severe pulmonary injury these are different than what we see with traditional overall hospitalizations sicknesses compare the two
Speaker 122
1:59:58
how many tobacco is continues to be the number one killer in
Speaker 222
2:00:08
no question on that I think the causes of hospitalizations are cancer heart heart disease, hypertension, stroke, so those are chronic, sometimes late-in-life conditions. This looks to me like a chemical exposure in your lungs from some substance or substances in a process that's delivered through a common device. And we'll learn more over time, and I'm sure the scientists and the CDC are going to track down all these incident cases. So you
Speaker 122
2:00:37
can't really say that the commercially available products are more dangerous than
Speaker 166
2:00:42
Cigarettes, or? Representative Gonzalez, I think we're comparing apples and oranges right here. Comparing someone who
Speaker 170
2:00:50
ends up dying of cancer after 20 or 30 years of smoking is different than a 19-year-old who is in the hospital and after seven days, you know, seven days after vaping and ends up dying in an acute hospitalization. Both of those are tragic deaths, but you can see they're very, very different.
and we have not had decades and decades of e-cigarette use to be able to make those comparisons. We do know that what we're seeing now with these acute pulmonary injuries is worse and different than what we see in terms of the acute effects of other tobacco products. Now, what the long-term effects are, you know, we won't know until it's kind of too late for several generations. But you still
Speaker 120
2:01:40
can't say that those acute illnesses were caused from commercially available products.
They are more than likely black market products.
Speaker 167
2:01:47
We know that some cases were associated with so-called black market products, but some cases there's no history of black market use at all. So in those cases, they would most likely be due to commercial products. And I would just differentiate.
Speaker 233
2:02:00
They were caused by a commercially available delivery system.
Speaker 222
2:02:03
what's put into it can be mixed at your bathtub at home and sold across this state. Yeah, but it's proven people are going to use that no matter what we do.
Speaker 301
2:02:16
I understand. But the delivery product is your control point. Representative
Speaker 193
2:02:20
Gonzalez, I would encourage this committee at some
Speaker 241
2:02:23
point in time to hear from State Drug Director Lane in regards to how we are seeing an increased use of these type devices being utilized with illegal drugs, not just opioids as was the case in the school in Bentonville but others it is something that is is becoming a great concern not just here in Arkansas but throughout the country
Speaker 124
2:02:47
one final question is there any way that you can use a tobacco association settlement funds for education purposes on vape products I think actually we are we
Speaker 166
2:02:58
are doing that thank you thank you representative Brown. This is the final
question I have. Thank you, ma'am. I think it's me, Senator Irvin.
Senator Trent Garner
Unverified
2:03:09
Oh, I'm sorry. Thank you. Dr. Thompson,
I think some of the others mentioned, you mentioned multiple times the FDA letter, warning letter out to JUUL today. Can you tell me specifically the five
causes of action that the FDA cited as evidence against JUUL to prevent them from be able
Speaker 254
2:03:33
to do this morning letter? I know that one was that they gave information to Congress that they had withheld from the FDA application. I know
Senator Trent Garner
Unverified
2:03:41
that's one. I can get you the other four. Okay. From my research, I'm actually reading a letter right now. It seems that four out of the five causes of evidence are actually testimony from that July 24th through 25th 2019 meeting. The testimonial from three different
individuals one is a co-founder of a group called pave which is a parents against vaping and the other two testimonies are from their sons of the co-founders testifying about jewel representatives and what they were doing these claims as far as i can find online and maybe if you have different information it's unverified outside of that one testimony from those people the other one is from a generic letter from on jewel's website dealing with vaping and a kind of a generic term put on there for a mission
statement from the CEO. So even though the warning letter is, as you say,
deals with advertising, it appears to me that the FDA has no justifiable evidence that there has been any kind of direct advertising done in their excited evidence that they use for that warning lever. So I just want
to make sure that some of the testimony you seem to indicate that they were, it was a relation to their advertising as being an alternative product it seemed to be more and from the evidence I've seen that the FDA use it's more about the testimony during a congressional hearing from unverified
sources not directly related to any kind of advertising plan or
things done at a national level. Would
Speaker 188
2:05:07
you agree with that statement? No I would respectively strongly disagree with that statement. I think anybody that's seen the commercials recognize that
Speaker 222
2:05:15
it's being advertised as a modified risk reduction product. And Juul has not received approval from the Food and
Speaker 188
2:05:21
Drug Administration to advertise itself as that. Why would the FDA not include that as cited
Senator Trent Garner
Unverified
2:05:25
evidence in their warning letter that they sent out? It is in the letter. No, sir, I've read the letter. I have not seen what you're defining
as that. All right, I'm going to stop right here
because we're not the FDA and we can have that debate and we can have that debated at the federal level. I get your point and we are going to allow the industry to come at a later date and if they want to discuss and present their case I'm perfectly fine with that but I think it is significant that they have issued this warning no matter what the letter says an issue a warning has been issued so I do appreciate the questions but unless the letter is produced in front of us and then we can debate it with both sides that's fine but right now that doesn't seem like we're getting
anywhere with that unless we have the letter and we have lawyers from both sides debating that issue. Are there any other
questions to come before this? Thank you. Appreciate the testimony for everybody being here. We will continue this discussion and dialogue and we will be filing that interim study as well at the end of this committee meeting. And
I believe Senator Hendren will be filing an interim study on the taxation issues in revenue and tax.
There may be an opportunity, members of the committee, where we will meet jointly on this issue with rev and tax for further discussion. Thank you all for coming and for your
testimony today. All right. DHS. Members, we've had ongoing issues with our
medical transportation. and for Medicaid and we will invite the members of DHS to come forward I do want
to say one final thing that if anybody googles or searches through social media particularly those social media platforms that are targeted towards youth and you will see very aggressive advertising and marketing for these products. So just
do your own research. All right if you identify
yourself for the record you may proceed. Madam Chair
Speaker 309
2:07:58
I'm Kelly Link, Chief of Staff Legislative Intergovernmental
Speaker 310
2:08:03
Affairs at DHS. Good afternoon. Janet Mann, Director of the
Speaker 313
2:08:09
Division of Medical Services, DHS. Rob Zachridge, Chief Operating Officer
Speaker 315
2:08:15
of Southeast Trans. Cindy Washington, Arkansas Operations Director, Southeast Trans. All right.
Speaker 310
2:08:25
start. Thank you. Southeastern Trans is one of our brokers for transportation in the state.
state and I think some of the questions y'all had asked us about was their current corrective action plan that they are under we issued an early corrective action plan in May that was focused on network adequacy they have by July 1 they had reached over 50% of that in August there were still some questions about the network adequacy, so we did issue a damage letter to them for 645 missed rides
with a $500 fee for each one of those for about $391,000. In that process, we have continued to work with Southeast Trans. They came into three new regions in January when we had to fire a broker, and we have worked with them on getting their network in their vans working and moving and picking up people and not missing those rides we will continue to monitor that as we work through
this corrective action plan that's a that's a brief overview um i can either answer questions or allow southeast trans yeah
why don't you go ahead and um speak i know we were in a dire situation earlier with medical transportation and we had to fire our vendor and that was life or death situations that were occurring. There were patients that were not able to go to their chemotherapy appointments or their dialysis appointments and so we had to fire them. We understand this is a difficult
space that you've stepped into. However, I think it's important as members of this committee had requested that you be here to talk about the ongoing issues and problems that we may be facing because we hear from those individuals when they don't get picked up. Again, my name is Rob Zachreach, COO
Speaker 322
2:10:31
for Southeast Trans. Thank you for having us today, and thank you for asking us to come to meet with the committee.
We take our responsibility extremely serious. You're right. It is. We impact people's lives when they don't get transported. We took over a pretty tough transition in about eight days, but it's now September, and we're having issues. We will not rest until 100% of our transports go on. Right now, we're at 99.5% transportation is going on, but it's at 0.5% that is very, very important.
As far as I'm concerned, and the owner of Southeast Trans is concerned, those are our loved ones in the back of those vehicles, and we need to get them to and from their medical appointments. Cindy Washington is with me. She's the local operations manager, knows the details for any questions that may come up. We have, one of the things that we did when we started the program last year, we had 12 vehicles of our own, and we've been in the state for over six years and been a proud partner with Arkansas. We love this state. We love being a part of it, and we feel very close.
We now have over 100 employees that work in Arkansas. But one of the things that we did almost instantaneously when we saw the deficit of transportation providers is to bring in another, I think, close to 20 vehicles right away in February. So we started with 12, and as of the end of this month, we will be at 67 of our own vehicles. That's not where we really want to be. that's not our expertise we bring them the vehicles to fill the gaps of providers in the five regions that we're in today and we believe that by the end
of September we will be at that hundred percent when I say a hundred percent you are going to have missed trips we do 3200 trips a day and a vehicle might break down a driver calls in sick a driver quits you know as quickly and we have to scramble to place those transports but we believe the extra 28 vehicles that are literally being delivered every day and the drivers being trained today and last week and we've got six new vehicles on the road today but those 28 vehicles we put into the system by the end of the month and
we feel like that is more than enough to offset the deficit
of transportation providers thank you senator Caldwell did you want to
Senator Ronald Caldwell
Unverified
2:13:07
have questions no I appreciate y'all coming I was the one that had a constituent that was not picked up three different times for a chemo treatment so that's that's why you're here today and I know other legislators have had constituents that
had problems also and it's again when you make the comment that you feel like they're your family in the back it really is theirs and it really is a life and death situation not to be able to go have certain treatments and I appreciate y'all coming appreciate your effort in trying to rectify the problem and so but But again, it has been a major problem. I do appreciate Senator Irwin allowing y'all to come today and explain what you're doing.
So thank you very much. So just to follow up on a question, I know, thank you, Senator Caldwell, I'm happy to oblige. One of the things that, you know, I know it's a rural state, and these are different issues with urban versus rural, and that's something that we've discussed. But, you know, do you have the ability to subcontract, so to speak, with individuals that could utilize, like, a Lyft program or something like that where they use their own vehicles and they're available to do that?
It just seems like that would be a
better approach to some of the rural areas that we have where these people are missing their rides. We actually contract
Speaker 322
2:14:44
with Lyft in two of our states, and while they are a good system recovery type mode of transportation, there are some significant limitations. As in Arkansas, in Arkansas we know the vehicles, we know the drivers, we run background checks. We now have cameras in vehicles, which was a big change for us.
You're the first state that has cameras in the vehicles, which actually has paid up some dividends and because you you can't you can't deny what's going on what you see on the tape. Lyft and Uber or the TNCs have limitations because they don't run the background checks like we do they don't do the vehicle inspections like we do. Right but what
I'm what I'm saying though is that not necessarily subcontracting with Lyft but developing that same sort of model for your own company.
Speaker 330
2:15:33
And we are right yeah to we have a company that's owned by our owner
Speaker 322
2:15:39
Steve Adams it's just getting off the ground in Tennessee it's really in a pilot stage but it's a company called variety and it is fully compliant drivers fully compliant they've had the training they will have the in Arkansas our goal our vision is to bring this in when this program is proven but it would allow the especially the rural you could find a couple of drivers in those real rural areas where there isn't a Lyft or an Uber and dedicate them to the Southeast Trans Network and provide them transfer they would provide that
transportation and be reimbursed for that it's a what we visualize is a great way for a one-vehicle owner to get into the business and so we're we're excited about it I don't want to over promise it because I want to see
it up and running no I just think it's such a it's it's a good employment opportunity actually too
for someone in rural Arkansas who perhaps might be a retired person that might want to
do this I mean we have church members that do it for other
church members so I don't know why you wouldn't replicate you know something like that because you know I know our church and other churches have stepped up
to try to fill that space for their own church members to take them to doctors appointments and things like that so I mean I just think that there's areas to that we might need to be more creative and innovative on trying to solve this problem and maybe it is partnering up with our faith-based institutions dhs might could do that as well is how do we partner up with maybe faith-based institutions to say how can we how can you help us fill this need because that's really i mean i know that you're under contract
and there's a lot of money that you're paid to do this but in the end that
Speaker 313
2:17:25
could really be a ministry as well yes my my uh our ceo
steve adams has it has your same vision okay well anyway maybe we could do that as a state and encourage encourage faith-based partnerships and ministry opportunities just like we do with our restore hope summits anyway just a thought okay senator hammer
Senator Kim Hammer
Unverified
2:17:47
thank you madam chair first of all Kelly in
another area y'all assess fines in excess
of 200,000 and if I heard testimony right a while ago about 300,000 to this group that's over half a million just educate me work that much where's that money go back into your budget and how do we track it
Speaker 310
2:18:11
it will get back into our budget and we will have to credit the portion that belongs to the federal share on our seat on our quarterly CMS 164 report and then as it can be reused is as long as it
Senator Kim Hammer
Unverified
2:18:25
Qualifies under our appropriation act. Do you know how many dollars you've
assessed against providers across the board that you've recouped? I'm thinking of this one and I heard one in a committee meeting last week No, sir, I'd like to get a report on that if you don't mind, please. Yes, sir. And then to the provider 300,000 plus and fines and I'm reading over your handout, which I commend you for the investment that you made A lot of dollars against the original amount of the contract and I'm just wondering
Financially and I hear you talk about you know testimony in Tennessee what you want to bring here But those are some pretty hefty dollars that are shown in this report against what you originally bid the job for And so I'm wondering financially sustainable How are you I mean what are you guys gonna walk out of us 30 days from now or something? where we're going to have a
Speaker 312
2:19:18
problem like we did with the last one or give us some reassurance? No. I
Speaker 322
2:19:23
appreciate where you're coming from. That's a heavy lift that we received from DHS,
and we have a really strong partnership with DHS and the FMC. But we are responsible for that contract, and so that penalty is part of the contract, and so we understand that. No, we are going nowhere, unless you guys boot us out, and I don't expect that to happen. We love being here. We love being a part of your Medicaid program. And, yeah, we have invested around $3.5 million annually that will be over and above our budgeted expense for this.
But that's what it's going to take to get our network. And our goal is, yes, we're going to have 67 vehicles of our own by the end of September. Our goal is to find people who want to be entrepreneurs, who want to start with one vehicle or maybe two vehicles, hand those vehicles off over time we'd love to be back to 12 vehicles they transportation riders run better than we do but before the meantime we're gonna fill the void of the transportation providers and now we aren't we aren't
Senator Kim Hammer
Unverified
2:20:32
going anywhere don't worry about that can I get one more madam chair yes quick thank you so the original contract I'd like to hear the response from miss man and from you as the provider the original contract amount are we looking at y'all coming back and asking us for an adjustment in it in order for them to be able to get compensation or be able just to recover the cost of what it's taking to get this thing up and going and was that a seven year with one year one year renewable because i'm a little
concerned long range if you guys are going to be coming back and
Speaker 311
2:21:09
asking us for more money um i think they're always seven years one year renewable and so yes it is and virtually all contracts are adjusted through that seven-year period in one way or another so I don't know that that Southeast Transportation is ready to sit in front of this committee and talk about negotiations with DHS that may they may have in the future or vice versa but there's generally usually some sort of adjustment on
Speaker 338
2:21:31
yearly on the seven-year contract thank you ma'am chair thank you
Senator Ronald Caldwell
Unverified
2:21:37
senator Caldwell thank you madam chair go back to the question for DHS on the $300,000. Do you ever forgive any of that fine? Yes, sir. Once we
Speaker 311
2:21:49
do a corrective action plan and then assess any sort of a fine or penalty or whatever it may be, that's always negotiable. It may be something that we overlooked when we put that out there and said, hey, we're fining you for XYZ, and the company comes back and says, yeah, but you didn't notice that this happened, and these were not correct reports or whatever.
And so there's often negotiation back and forth on that amount of money.
Senator Ronald Caldwell
Unverified
2:22:14
Okay. I'd like to maybe toward the end of the calendar year look at, see how much of that fine stayed in place and how much of it was forgiven. Yes, sir. Not fussing at you all. Right. But to throw a figure out to, hey, we fined them $300,000, and in reality you didn't fine them anything. And I'd just like to keep up with that, see really what we did. We'll certainly let you
Speaker 309
2:22:35
know how the negotiations come out. Thank you, Madam Chair. Thank you, Senator Caldwell,
and I really do appreciate everybody at the table.
Representative Brown, one last question. Thank
Speaker 137
2:22:48
you, Madam Chair. I'm just curious about the vendors that you hire. Do you compensate them well enough to stay with you? I'm particularly asking about a specific situation that I'm familiar with, that it's
Speaker 141
2:23:06
my understanding according to your business model you pay mileage only but if a driver arrives to pick up somebody and they have to wait sometimes you know a considerable
amount of time they still have to be paid and and according to your business model you did not pay for wait time you only paid mileage when you do that how is it possible for a vendor to to be there for you great
Speaker 322
2:23:38
question and we there are situations where if a transport has a some anomaly to it where the rider has to stay a couple hours or wait and it's not worth them coming back we will talk to them and what we call
that is a special rate meaning it's and we don't actually just pay mileage we play a base rate and up for any trip under a certain number of miles and then on top of that if once they exceed six miles or seven miles then there's a mileage rate on top of that base rate so that's typically our contract with the providers and one of the things that we have done is adjusted the pay rates of some of our providers where we were having some of the more challenging areas to motivate them to take more trips to add vehicles to expand their
hours of service if they were maybe starting up at six or eight o'clock and and we needed them at five o'clock because we had that many more dialysis pickups during that time, we've done that. So it is something that is fluid. We've been, I think Cindy recently negotiated, I think six new contracts with providers to adjust their fees so that they were making sure that we were paying them fairly. And again, we do, if somebody goes out of their,
They have a service area where we typically hire a provider. If we ask them, hey, I know it's not in your service area, but it's up in Fayetteville. Can you run that? And it may be a five-mile trip, and they've got to drive from Little Rock to Fayetteville. We're going to pay them for those miles
Speaker 313
2:25:13
and make it so that they can make money as well on
Speaker 137
2:25:18
that trip. They wouldn't lose money. Does that help? Well, it helps, and
Speaker 141
2:25:21
I heard your explanation, but I know this particular vendor had geared up to work with you
and just could not, was just at loggerheads with adequate compensation. Okay. I would be glad to speak maybe afterward
Speaker 345
2:25:34
about that. Thank you. Okay. Thank you. Any other questions? All right, Sinan, I really do
appreciate the discussion on this. I know it's important for us as legislators to be able to say something to our constituents as well. So if you do have a problem with a constituent that does call you immediately call Kelly Leak
Or text him putting him on the spot or Janet man So that they can take care of that problem as soon as possible Thank you and thank you for being here and thank you for your answers. We don't often hear that it's okay It's part of our contract that we're penalized. I do appreciate that. Thank you. Thank you. All right We're gonna move down the next discussion we're going to discuss the behavioral health and development disabilities assessment process and also we did have two people that signed up to speak on
transportation issues that were at the table but we also have with Easterseals the and that was a transportation issue as well and so if you can just meet me after the meeting I'll try to help take care of your issues that's okay thank you and it was
on transportation is that correct you're good okay okay thank you for being
here though we do appreciate that okay behavioral health and
developmental disabilities assessment process members of the committee this is something that I know was discussed at length at Legislative Council last month And as I have tried to understand this issue and do a lot of research on my own, I think you have three different things that we're really trying to
figure out in this space, which is process, policy, and performance. And I stole that from Kelly Link. But it is true.
So I think a lot of the issues with this assessment is the process that happened, but the process that was assumed and put in place by DHS, that wasn't necessarily the process that was working or that was followed by the providers seeking the assessment. So, you know, you have a lot of people in this arena. You've got DHS, you've got the providers that are behavioral health providers, and you also have primary care physicians.
and you also have parents, and then you also have Optum, who is the contract that does the independent assessments. You also have EQ Health that does the recommendations. So there's a whole bunch of people in this space, and so for all of this to go right, there needs to be a process that's followed. And unfortunately, that process really hasn't been followed, or there's been problems with it. So that's why I wanted to have a brief discussion about this with you at the table to discuss this because I think we sometimes get misinformation or we get confused as legislators when we're speaking to constituents or we're speaking with providers or lobbyists or whomever that is in this space.
So with that, I think I want you to talk about the process that has occurred and the things that you're doing to try
to fix that process so that it works better for everybody in that space. Go. Good
Speaker 348
2:29:07
afternoon. I'm Paula Stone. I'm with the Division of Medical Services, Arkansas Medicaid. And so thank you, Senator Irvin, because you set the groundwork for us very well. So we've been doing independent assessments for the behavioral health population since
2017, August of 2017. And for the behavioral health population, they receive an independent assessment to go into the PASS system or to receive some services that are to address a functional deficit. So just to remind everyone, the independent assessment in this case is a functional assessment. So all of the individuals who get the independent assessment on the behavioral health side have a behavioral health diagnosis and have been given that diagnosis by a professional.
If they need additional services, then they can get the independent assessment. And those additional services are home and community-based services provided by a paraprofessional. For the behavioral health population, we serve children ages three up to individuals who are in their 90s. So it's a large group of people that have been served through behavioral health services. And so the needs of children under the age of 18 in particular are very different than
those that are adults. So adults that come into the system are seriously mentally ill, and they have Medicaid eligibility generally through Social Security disability. So they've already been deemed disabled. The children, on the other hand, have not been deemed disabled and have a variety of levels of needs. So when we set up the program, we allowed for the behavioral health provider to both give a diagnosis of the behavioral health disorder, treat that behavioral health disorder
with counseling services provided by professionals, medication management provided by physicians, And then if they needed these home and community-based services to refer them for an independent assessment. So that independent assessment referral process goes through our vendor, EQ Health, who does our prior authorizations for services or extension of benefits. Our assumption at that point in time would be that the behavioral health provider would provide behavioral health services, counseling services, if they needed more.
Then at the time they were asking for more behavioral health counseling services that that they might also then ask for an independent assessment. What we're seeing is that's not what is happening. That most of the behavioral health providers are referring people very quickly without going through that process of giving a lot of counseling services prior to that. So that's one of the things that we've started working on. So I know that a letter was sent saying that the behavioral health process for independent assessment is not going ... It is still a little difficult.
And I think what we are doing now is looking at that process. The other thing that happens for the behavioral health population is they have to receive an annual reassessment to remain in the past. And that annual reassessment is because we believe people with behavioral health disorders can recover. That is one of the basic tenets of providing treatment to individuals with behavioral health disorders is that they get better with treatment. And so what we're doing is making sure that they still need that level of services. So a reassessment happens every year.
That reassessment process is new for us. We started that this year after January was the first round we had of reassessment. And that is now with the passes. So we've worked very diligently with the passes because now all those individuals in a pass have a care coordinator, so the care coordinators are now working with Optum. So that's a brand new system that we've put into place. So we continue to work on that process of getting those individuals referred for that reassessment and making sure that that happens. So we continue to meet with organizations, the provider organizations for behavioral
health, with Optum, as Senator Irvin mentioned, it's multiple contractors, so EQ Health, it's Optum, and we actually even have DXC in there a
Speaker 349
2:33:17
little bit because they're the ones that are providing all of the data back and
forth. All right, thank you. So members, if you have an issue on, I think it's important to note that if you have an
issue on somebody who's doing the assessment and they're not performing the assessment appropriately or something that's a performance issue
that's under the contract of Optum timeliness could be a number of different factors the parents might not be calling you know or they make a referral so there's a misunderstanding I think a little bit about that so there's a lot of different things going on here so I know I just wanted to make sure and for me it's important that not every child goes into the past not every child who has the ADHD is taking medication that's not necessarily a child or a candidate that needs an independent assessment that would then
go for more services so there's there's a lot of that happening too and I think there was an immediate assumption that every single person in Medicaid needed and independent assessment. That's not correct. This is only a certain population that we're talking about. Those with, go ahead. I don't want to speak. No, that is correct because I
Speaker 348
2:34:36
know that when we looked back at our behavioral health population, when we were looking at transformation and with the health care task force is we saw that we have about 100,000
people in any given year with Medicaid that had a behavioral health diagnosis and got least one behavioral health service funded by medicaid 100 000 people our projections were that we were only going to have about 25 000 of those individuals that needed that full array of home and community-based services in addition to the counseling so it was a small portion of the total population of 100 000. representative lightening thank you madam chair uh
Representative Jack Ladyman
Unverified
2:35:16
my question might be a little bit off the subject here but
But the new crisis centers that are starting up around the state, we have four of those. And the one in Jonesboro will be opening tomorrow, grand opening, I guess. But some of them, like the one in Fort Smith, in Representative Boyd's area, I believe, has been open for quite some time. In Jonesboro, that facility, we had some concern because there's 16 beds and it's serving 20 counties. So would we be able to handle that? and i talked with the director of facility up by fort smith about the numbers and and their
their numbers that they're serving are quite large and they're turning these people within 24 hours in many cases so there could be a lot of people going through this process so my question is how is that going to affect the numbers of people that you serve is that going to be a plus or a minus I mean maybe they get services faster so you don't have as big a problem or maybe it overloads the system so what's your thoughts about that I know the numbers it's new we may not have a lot
of numbers but how do you think that will affect
Speaker 348
2:36:29
the system so as I was saying earlier the difference between adults and children so our challenges with adults have been that adults have not consistently or not all adults have consistently gone and sought the services of an outpatient clinic. So we see a lot of them that either go into a crisis unit or go into a hospital. They present in a hospital emergency room with symptoms of psychosis or other serious symptoms. Many times they're
admitted to a hospital if there's a bed available so the crisis units were very much welcome to both keep people out of hospital settings and stabilize them in community settings and not only was there money given for those crisis units that's also a service that Medicaid funds we call them the acute crisis units on the Medicaid side so there's Medicaid funding to provide that service much like it could have been provided in a hospital setting and one
One of the things that we know about adults that present in those settings is that the more quickly you can get them assessed and stabilized, but then to also have the correct services for them once they leave that acute setting. So that's one of the things that we have hope for is that we'll be able to, and we have been able to focus optimum assessors on those acute settings so before adults are released back into the community, they can get that independent assessment if the medical professional who's assessed them medically believes that they need those additional services, get them
independently assessed if they're Medicaid eligible, and then get them into a pass more quickly before they go back out into the community. So we've been able to see some ability for us to get those people assessed before they leave. That's really our hope is to have a focus, focus our independent assessors on those individuals, particularly those adults. So we can also start tracking those numbers that have come from adult crisis units
and get that back to you
Speaker 111
2:38:42
as well. Thank you. All right, Senator
Senator Kim Hammer
Unverified
2:38:46
Hammer. Thank you, Madam Chair. A week ago or so we were in committee meeting and you all assessed Optima a penalty. So I'm thinking back to Senator Caldwell's question, testimony, previous subject matter. is there going to be a full assessment or do you see forgiveness because I think there was beginning there was probably mutual shared
responsibility about this thing launching are you all at liberty to say whether any
Speaker 338
2:39:12
of that is going to be forgiven down I'm
Speaker 309
2:39:17
looking at these two to see if they're involved in negotiations
Speaker 354
2:39:21
or not it's procurement Janet it is you can have
Speaker 310
2:39:25
that I apologize Senator, we took that into account when we assessed the penalty with Optum and Optum. There has been no conversation to reduce that penalty as of today.
All right. Thank you, Madam Chair. Thank you. Any other questions? All
right. Thank you. I very much appreciate it. The conversation, to continue the conversation, I appreciate y'all meeting with the behavioral health providers as well. I think that's important that we continue to work through this
process and figure this out. Appreciate it. Thank you. All right, moving
on. The Arkansas Minority Health Commission Annual Report.
Thank you for waiting and being here. This is a long meeting,
Speaker 360
2:40:29
I know, but we had a lot on our agenda today. Good afternoon, I'm Sharonda Love, Director for the Arkansas Minority Health Commission and I appreciate the opportunity to come and present our annual report. This is our requirement we have to report by October 1 each year and you have a copy
our slides as well as our annual report that provides an overview of the work that we've done through this past fiscal year we have continued to increase our citizen encounters and health education encounters this past year we reached over 34,000 individuals providing over 25,000 health screenings and collaborating with over or collaborating with 113 partners reaching 67 out of our
75 counties as you all know our goal is to reach all 75 counties and we have our new mobile health unit initiative we have just been on the road since the last week of March through June 30th we were able to reach 24 counties providing over 3,000 screenings and so it is our goal to utilize that mobile unit to provide access to screenings in all 75 counties
and I think we will definitely be able to reach that goal with the numbers that we have seen thus far. We also continue to develop partnerships with collaborators like Healthy Active Arkansas, the Arkansas Public Health Association, and the State Social Work Association to help improve professional development within the state. And we also continue to produce our annual
Bridge Magazine that reaches all 75 counties through the local health units as well as UAMS and children's hospitals. So at this time, I know it's been a long meeting, you've got access to the report. I will take any questions you may
Speaker 361
2:42:39
have. Thank you. Senator Hammer. Thank you, Madam Chair. You've been sitting in the
Senator Kim Hammer
Unverified
2:42:46
room the whole time, haven't you? Yes, sir. So you heard the discussion on the vaping a
while ago is there anything that you do when you go out to educate
people about the issue of vaping or are you prohibited from discussing
Speaker 360
2:43:03
that no we um we definitely promote and provide health education as it relates to tobacco cessation as well as vaping cessation and we were able to work with several back to school fairs just this
Speaker 365
2:43:18
summer to provide education and tobacco-free pledge cards to youth to pledge to be tobacco-free throughout the school
Senator Kim Hammer
Unverified
2:43:27
year. What message do you give them about vaping?
Just don't do it or it's a safe alternative to smoking. What's the message? Our message
Speaker 365
2:43:38
is to not do it, and we work directly with the Department of Health to provide health education materials as it relates
to it. All right. Thank you, Madam Chair. thank you see 81
Representative Vivian Flowers
Unverified
2:43:57
representative flowers thank you I'll make this quick I just wanted to commend you and your team on the incredible work and the outreach
that you guys have achieved and I'm saying this as a former member of the Commission of nearly a decade I'm super excited and happy about elated about the mobile health unit and that said I just would ask do you guys have any plans on regenerating the television show that and I'm saying this knowing we've talked about it before but I know you've gotten a lot of stuff off your plate and you're doing great things I just would love to see people across the state know more
Speaker 360
2:44:37
about what you do thank you thank you for that question representative flowers and yes we have talked about that there there are currently no plans for this current fiscal year simply because as you know we've been trying to rebuild the the staff and the capacity at the Commission we are now fully staffed and I think that is something that we can begin to look into in the future how we can move forward with making that happen I have a suggestion I think we need to
hook you up with AETN so that you have a regular spot on there and I don't know why we couldn't make that happen because i agree with represent flowers y'all do wonderful work and it's really really important the outreach that you do so i'm wondering if we can't do
figure out a way to hook you up to where you have a regular regular appearance on aetn i would be happy to work
Representative Vivian Flowers
Unverified
2:45:33
with you to do that i'll work to madam chair yes ma'am if i a great minds think alike
I was actually at ATN for something different and talked to the leadership there and I can just I'd love to say publicly that they are open willing and super excited at doing that so I think the pathway is open for you to do that and great and you have
bipartisan support for that so yay yeah I'll representative flowers
and I'll visit with Marty Ryle and figure out how way we can get that done because I think you have a great report and you do great work great outreach and
you reach all the counties and I think a lot of people don't understand that about the minority health commission that it's actually all over and it helps people in all economic areas too thank you thank
you representative flowers sounds like we have work to do senator
Senator Kim Hammer
Unverified
2:46:31
hammer thank you madam chair I'm looking on page 21 of your report and
I'm thinking back to a conversation we had earlier today that Arkansas is the sixth highest adult obesity rate in the nation. What measurable results can you see with what you've done in order to get us off that sixth
Speaker 360
2:46:51
number? You know, that is an initiative that we continue to work on. The Minority Health Commission has been actively working with the Governor's Healthy Act of Arkansas initiative to make sure that we are getting education as well as interventions to Arkansans to help us to be at a normal weight. We are definitely seeing progress from where we were 10 years ago, but it's work that we still have to get done here within our state.
Senator Kim Hammer
Unverified
2:47:22
You don't have to respond to this, but I'll put a formal question at the end. I'm just thinking for the areas that we're dealing with, like with vaping and what we're talking about as far as solutions and dealing with that, that we ought to apply the same standards to obesity and maybe we ought to look at taxing higher fat foods and things that contribute to obesity um i don't want to be quoted necessarily as that but i think we need to have a standard of fairness across the board um if we're going to hold one standard we're going to hold the one we need to take that standard across the board
otherwise i think we're we're being a little bit hypocritical would you agree no don't have
to answered. Thank you. Thank you, Senator Hammer. Any other questions? Thank you. Appreciate your report. I
do think the challenge with with vaping right now is there's not a unified message. We can just say don't do it, but I mean if you don't give your kids a viable reason as to why they shouldn't do it, then they're just going to look at you and go, well, I'm just going to ignore that, right? So I think that's the challenge right now is what is the what is the unified message right now
but I mean when you talk about anybody who has COPD shouldn't be vaping right so I mean you you have to think about the combination of what these people have higher instances of strokes or myocardial infarctions and how that could exasperate it because of a lung issue I mean those are some real serious issues but it's hard in your position right now to really counsel anybody because we just don't know right it's just and you're you're fighting something that's
really cool and there's a skin that's you know for sure that you can buy that's really cool anyway thank you for
your report all right moving on representative ladyman thank you madam chair i
Representative Jack Ladyman
Unverified
2:49:12
had a question about your mobile health units and you go in all the counties are trying to address all the counties but do you go to the same sites two or three times and and is there any way of measuring effectiveness I mean like if you go to one site and you go back a year later
do the numbers come up do you see improvements in any areas so far we
Speaker 360
2:49:36
have not been to the same sites simply because we have only been on the road since the last week of March but it is clearly our intent to continue to go back we have a partnership with the arkansas food bank and we have been going to food pantries and developing those relationships so that we are able to go back and and will be able to continue to work with individuals year after year one good thing about our mobile health
unit that's different from the health fairs that we normally do is that when individuals come to health fairs they come in and we collect no information so there is no way for us to follow up with them however with our mobile health unit we are able to collect demographic information and phone numbers and addresses so that if there is an abnormal screening we can number one refer them on to a resource at the local level so that they can be seen but then also follow up at six
at three, six, and 12 months to see if they were able to follow through with those resources that we provided for them and if they had any barriers to work with them to see how we can help to alleviate those barriers. Thank you. Any other questions?
All right. Thank you so much for your report. Thank you, Madam Chairman and committee members. Thank you. And maybe at one of our meetings we'll have the mobile health unit come and we can tour it. I would
love to have that happen. Okay. All right. we'll work to get that done too. All right. Thank you. Item I. Ms. Cook, thank you for waiting.
hi if you will just state your name for the record you may proceed Jamie Cook oh sorry
Speaker 383
2:51:35
secretary for the Arkansas Department of Public Safety as well as the Director
Speaker 385
2:51:39
for the Division on Law Enforcement Standards and Training.
Thank you. Go ahead. In this last legislative session, Act 151 was passed. Basically, it was a cleanup bill for the Division on Law Enforcement Standards and Training just to streamline our efforts, reduce any over-burdensome bureaucracy. We successfully got that through the session. these rule changes before you today are reflective of those changes we took the
opportunity to incorporate Act 315 into these rule changes which repealed all 22 of our specifications most of those were integrated into the rules we also repealed three rules and then an act 910 it created the division on law enforcement standards and training before that the Commission on law enforcement standards and training reference both the Commission and the
state agency so act 910 created that clarification that we do have a ten board commission that sets the rules for law enforcement training and standards in Arkansas and the agency that actually sets that out in the form of our training academies at Alita Northwest Alita and our standards office here in Little Rock so with that if you would like me to go into detail on the specific rule changes I'm glad to do so otherwise I'll take any questions
members if you will look through this it's exhibit I if you have any questions we can entertain questions but it looks like it's just moving it correct and then specifying making different specifications but I appreciate the fact that you have so for instance you have Act 820 in there for the expedited licensure issue so you've included that and you've
responded to legislative changes yes ma'am are there any questions and repealed a bunch too
that's always good all right CNN thank you this rule will be approved without objection. All right. Item J. That's okay.
It's okay. Everybody's left.
Speaker 389
2:54:47
Michael Grappay, Arkansas Department of Energy and Environment.
Speaker 390
2:54:54
Kay Joyner, Arkansas, or the Division
Speaker 391
2:55:01
of ADEQ. DEQ, I'm sorry. I'm within DEQ.
Speaker 393
2:55:05
I'm with the Arkansas Energy Office. Okay. Thank you. Go ahead. Okay. earlier this year we passed legislation called act 790 of 2019 which required us to provide a state plan for the weatherization weatherization right for the weatherization you had that plan before you in December of this year will also be required
Speaker 389
2:55:30
under the same act to give you a how are we doing update and then in the second quarter of next year we'll give you a final how we did
had to report so the report you have in front of you is the one that we give to the Department of Energy who approves the program is completely federally funded so if you have
any questions Miss Kaye will be glad to answer them for you so this is a federally funded 100% is that correct
100% federally funded program and that provides assistance to households so that they can conserve energy is that correct and it's income based that's correct it's
poverty level okay and do we then contract with companies that will go in and do this we do
Speaker 390
2:56:30
programs around the state they're all non-profits they do the weatherization work okay representative ladyman thank
Representative Jack Ladyman
Unverified
2:56:39
you madam chair is there a set amount of funds that are available to Arkansas or is this like a large sum
of money that you can get if we meet certain criteria yes it's
Speaker 394
2:56:54
it's a block grant program so each state receives an allocation okay
Representative Jack Ladyman
Unverified
2:56:59
uh follow up yeah uh so are we spending all of our allocation are we spending a percentage are you getting applications enough applications to utilize those funds that are available yes sir we do
Speaker 394
2:57:10
um we actually in some of the counties there are waiting lists for weatherization services do you see more
Representative Jack Ladyman
Unverified
2:57:18
need in certain parts of the state or is it pretty much across the board for your projects it's
Speaker 390
2:57:26
it's across the board um you know it's uh based on uh low to moderate
Speaker 394
2:57:32
income households and the ones that um the houses that need it the most are the older houses you know that haven't been brought up to standards for energy efficiency all right
thank you and these are homes that are owned by the individual not a landlord issue landlord based They
Speaker 394
2:57:52
can be landlord-based. They can be? Yes, they can. The funding is intended to go to the occupant of the household that's paying the utility bills.
But we're making a physical improvement on a home that's not... i
mean so how do people wouldn't wouldn't people that have property though maybe say oh i'm just not going to put a new roof on that house and i'll let the federal taxpayers do it even though they're a business person they can afford to do it how is how are we checking to see if that's not happening well the way the
Speaker 394
2:58:41
program is set up by the department of energy
is that they want the benefit to accrue to the person living in the home who is eligible based on their income, and they want them to have a house that is more energy efficient so they pay lower utility bills because they're the ones that... Well, I
understand that, but the benefit's not really going to the individual. I mean, the benefit's going, if it's a new HVAC system, then the benefit's going to the landowner.
Speaker 392
2:59:18
That's true, but it also benefits the tenant in that house regardless. I don't disagree with that, but I have a problem
Speaker 402
2:59:30
with this. It's a federal guideline. We didn't make the rules. I know. Yeah. but there's
no way for us to there's no way to for us to
Speaker 394
2:59:46
track do we track that well the large majority of the houses that we do are owner-occupied I mean I
don't could you keep a statistic on that we do have a statistic
on that I don't okay happen to have it with me okay if you don't
Representative Jack Ladyman
Unverified
3:00:05
mind sending that to me I would really appreciate it we'll be glad to get that to you yes Well, my question was, maybe you've already answered that, but where it might be a landlord, I understand what you're saying, that the person in that home that is renting that home more than likely pays the utility bills. I don't know whether you track that or not, but if that person, the renter, is paying
the utility bills, then the savings does go directly to that person living in the house, even though they don't own the house. But to Senator Irvin's point, you could have landlords taking advantage of that program to offset their cost of maintenance. That is possible. So do you, are you required to, or does the program ask you to track, you know, how long the renters stay there? Or is the house always rented? I mean, is there any way of tracking that to find out whether a landlord is taking advantage of a federal program?
Speaker 394
3:01:00
well the way the program works is that there's an energy audit done on the house and the measures that are actually installed on the house have to be cost effective over the life of the measure so the cost of say for example attic insulation has to be cost effective in other words the energy savings will pay for that measure over the life of the measure so it isn't
that we go in and just do improvements to the home they have to be energy related and we don't we don't do roofs so that's you know there are many many times that we actually defer a house if the infrastructure is just so poor that we cannot really install the energy-saving measures. It's not economical. I understand, and overall, that
Representative Jack Ladyman
Unverified
3:01:58
it's going to be an energy reduction program,
so it's going to reduce the amount of energy used statewide, and that's a good thing because then your infrastructure and the power supply needed and all that, it's a benefit to that as well. And I know a couple of people that have actually benefited from this program and have raved about it. It's been a very good program. But I think you do need to watch and monitor where it's a landlord that's doing this, and that might be done by repeating.
You know, you have this landlord repeating with multiple properties and so forth. I think that's something that should really be looked
at. Thank you. I agree. even if it's a federal program is there anything that we as a state could
do to tighten that up can we do you know yes or no find out about that you
Speaker 390
3:02:51
can we we used to charge we used to charge a fee
Speaker 394
3:02:54
for landlord of a landlord but the Department of Energy does not allow us to do that anymore because they want the benefit to go to the to the tenant and they're afraid that the landlord just
will not agree to have their house improved energy efficiency-wise, and then their tenant will not have that benefit that they're entitled to in terms of their eligibility. So it is a kind of, it is a sticking point. But I think, if I'm not mistaken, that I think that only 15% of the program is done in renter-occupied dwelling units.
So the large majority goes to owner-occupied units. Okay, well, I'd like to just
further explore this because I just don't want to see people taking advantage of that. All right.
Senator Kim Hammer
Unverified
3:03:56
Senator Hammer. Thank you, Madam Chair. Is there preference given to a home that's owned by a landlord versus a home that's owned by an individual?
owner as far as who
Speaker 394
3:04:16
um eligibility is based on the whoever occupies the home and so we don't give any advantage to the to a landlord because because it's the tenant who's on the waiting list or whatever and if they're um we do give it advantage to an elderly person or a disabled person or a household that has young children has children in it so those
Speaker 401
3:04:45
are the types of priorities that the program establishes so if you're on limited funds
Senator Kim Hammer
Unverified
3:04:50
and do not have enough funds to go
around which is i think what i've always heard about this is there's never enough money to go around would it require legislative action or could you do it on your own to put homes that when the landlord is applying, that you would put them at the bottom of the list so that everybody above them would get access to the money first?
Speaker 394
3:05:18
Well, I think that that would be something that we would have to discuss with the Department of Energy because it is 100% federal program, and they create the guidelines by which we run the program. So we couldn't put landlords at the bottom of the list if
Speaker 401
3:05:37
their tenants are very needy, basically. Okay. Thank you, Madam Chair. Thank you. All right.
I have one last question, and then I have to be in northwest Arkansas. Go ahead,
Speaker 141
3:05:54
Representative Brown. When we speak of weatherization, there's so many things that that entails. I mean, it's like weather stripping around doors and windows and filling holes and adding insulation and things like that. So could you kind of just, like, what do you typically do to a house? Well, the first thing we do is
Speaker 394
3:06:13
go in and do an energy audit, which is to assess the home for all those measures.
And those go costly if you pay for one. Yes, we do. We have very qualified staff that go out and collect information on each home, and then they enter it into a software program that does the cost-benefit calculation. So all the things you mentioned are things that we do, the weather stripping, the air sealing, all types of insulation, attic, wall, and floor insulation. we do evaluate heating and air systems
and we can we can do a tune-up for the you know the basic thing is doing a tune-up for the heat and air we can also repair the heat and air we can also replace it but as I said it has to be cost effective so we don't replace that many heat and air units the other things that we look at are the we can replace a
refrigerator if it's a high energy user so we have we meter those refrigerators when we go in and do the audit to see exactly what their energy usage is and And so refrigerators, we can replace water heaters. But a lot of times that's a health and safety issue because they're leaking or they're not operating properly, which if they're gas,
Speaker 392
3:07:52
you know, that could create a problem.
Speaker 120
3:07:58
Thank you. Representative Gonzalez, last question. Thank you. I'll be real quick. Is it income-based only or are assets considered as
well? it's income-based yes thank you I want to do a little more research on this program thank you thank you I don't believe there's any other business coming before us in the committee I just want to thank Allison I want to thank
you for being here today mr. price is out for personal reasons you
did great thank you can never do it without our staff yes sir I
have to file it so we will follow it right after the meeting and then we'll take action on the ISP at the next
meeting thank you sir any other business to come before us before committee thank you if not we're adjourned
Unknown speaker
3:09:02
Thank you.
Thank you.
Thank you.
Thank you.
Thank you.
Thank you.
You
Agenda
Call to Order
Comments by the Chairs
Consideration to Adopt the August 19, 2019 Meeting Minutes (EXHIBIT C)
Arkansas Department of Health (ADH), Arkansas Prescription Drug Monitoring Program Report—Opioid Discussion
E. E-Cigarette Products, Nicotine Exposure, and Vaping (EXHIBITS E-1: ISP, E-2: Governor’s Proclamation) (HANDOUTS: PowerPoint Copy, plus 4 Other Handouts)
F. Status of Medicaid Transportation Subcontractors
G. Behavioral Health and Developmental Disabilities Assessment Process
H. Arkansas Minority Health Commission Annual Report (ACA 20-2-103)
I. Commission on Law Enforcement Standards and Training (CLEST), Review of Rule which Updates the Rules with the Changes from the 2019 Session of the General Assembly.
J. Weatherization Assistance Program, Arkansas Energy Office of the Arkansas Department of Environmental Quality (ADEQ) Report to the House and Senate Public Health, Welfare and Labor Committee (Act 790 of 2019) (EXHIBIT J)
Other Business
Adjournment
Documents
| Title | Type | Pages | Source |
|---|---|---|---|
| Agenda — PUBLIC HEALTH WELFARE AND LABOR COMMITTEE - SENATE AND HOUSE, Sep 9, 2019 | Agenda | 2 | Official source ↗ |
| Exhibit C Draft Minutes 8-19-19 | Exhibit | 3 | Official source ↗ |
| Exhibit E-1 Draft ISP on Vaping | Exhibit | 4 needs OCR | Official source ↗ |
| Exhibit E-2 Governor's Proclamation on Ovarian Cancer | Exhibit | 1 needs OCR | Official source ↗ |
| Exhibit I CLEST Proposed Rule Change | Exhibit | 20 needs OCR | Official source ↗ |
| Exhibit J Weatherization Assistance Program Report | Exhibit | 28 needs OCR | Official source ↗ |
| Handout 1-4 ADH, ACHI, DHS | Exhibit | 38 needs OCR | Official source ↗ |
| Handout 5 AR Minority Health Commission Presentation_2019 | Exhibit | 16 needs OCR | Official source ↗ |
Speakers
Speaker 2
Senator Missy Irvin Chair
Unverified
Representative Jack Ladyman
Unverified
Speaker 21
Speaker 15
Speaker 30
Speaker 31
Speaker 55
Speaker 57
Speaker 59
Speaker 43
Senator Kim Hammer
Unverified
Speaker 82
Speaker 89
Speaker 77
Speaker 36
Speaker 102
Speaker 81
Speaker 120
Speaker 122
Speaker 127
Speaker 137
Speaker 141
Speaker 152
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Speaker 155
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Speaker 220
Speaker 222
Speaker 224
Speaker 233
Speaker 236
Speaker 241
Senator Jim Hendren
Unverified
Senator Trent Garner
Unverified
Speaker 269
Speaker 275
Speaker 223
Speaker 124
Representative Josh Miller
Unverified
Speaker 254
Speaker 274
Speaker 250
Speaker 301
Speaker 309
Speaker 310
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Speaker 315
Speaker 145
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Senator Ronald Caldwell
Unverified
Speaker 330
Speaker 312
Speaker 311
Speaker 338
Speaker 345
Speaker 348
Speaker 349
Speaker 111
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Speaker 360
Speaker 361
Speaker 365
Representative Vivian Flowers
Unverified
Speaker 383
Speaker 385
Speaker 389
Speaker 390
Speaker 391
Speaker 393
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Speaker 394
Speaker 402
Speaker 410
Speaker 401