Health and Human Services Committee on January 18, 2017

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The Committee on Health and Human Services met at 1:30 p.m. on Wednesday, January 18, 2017, in Room 1510 of the State Capitol, Lincoln, Nebraska, for the purpose of conducting a public hearing on LB18, LB19, and LB33. Senators present: Merv Riepe, Chairperson; Steve Erdman, Vice Chairperson; Sue Crawford; Mark Kolterman; Lou Ann Linehan; and Matt Williams. Senators absent: Sara Howard.

SENATOR RIEPE

If we can, it's 1:30; I'd like to get started on time so we can be respectful of your time and all the committee members. We welcome you today to the Health and Human Services Committee. Welcome to the committee hearing. My name is Merv Riepe; I'm from the Omaha, Millard, and Ralston district which is Legislative District 12. I happen to serve as chairman of this committee. The committee will take up bills in the order posted. Our hearing today is your public part of the legislative process. This is your opportunity to express your position and on the proposed legislation before us today. The committee members will come and go during the hearing. As senators, we need to introduce bills in other committees, and it is not an indication that we are not interested in the bill being heard in this committee, just part of the process. To better facilitate today's proceeding, I ask that you abide by the following procedures--the information is posted on the chart to my left--and that is to please silent or turn off your cell phones, to move to the reserved chairs when you're ready to testify so that we don't lose time in that process. The order of testimony is fundamentally: the introducer; we will then go to the proponents; we'll go to the opponents; we will go to the neutral; and at that point in time we will go to the closing. Following the closing, the clerk, who is Tyler Mahood to my left, will read off any letters that we have, either in support of or in opposition or neutral to the bill at question. If you're a testifier, please hand in your orange sign-in sheet to the committee clerk-- that's Tyler--when you come up to testify. And we're going to ask you to please spell your name, first and last, for the record before you testify. That's critically important so that we get this record clear. We ask you also to be concise. It is our request that you limit your testimony to five minutes. We'll be working on the five-minute clock which is four minutes under green--Tyler will be keeping, so if you have any complaints about the clock, it's Tyler. It will go to a yellow, just like traffic lights, and then when we hit the red, we'll ask you to stop. Also today to my right is Kristen Stiffler, who's our legal counsel to the committee. We also have Brianne Hellstrom, who's one of our pages; Brianne, over here, is from California, and also Jordan Snader, who is from Oakland, Nebraska. With that, I would like to start to my right for introductions. One of our committee members is now sitting at the mic.

SENATOR KOLTERMAN

Senator Kolterman, District 24.

SENATOR RIEPE

Thank you.

SENATOR ERDMAN

Steve Erdman, District 47, way out west by Chimney Rock.

SENATOR CRAWFORD

Good afternoon. Senator Sue Crawford, District 45, which is eastern Sarpy County, Bellevue, and Offutt.

SENATOR WILLIAMS

Matt Williams, District 36.

SENATOR LINEHAN

Lou Ann Linehan, western Douglas County, to include Elkhorn.

SENATOR RIEPE

Okay, thank you very much. With that, our first bill for hearing today is LB18. It's a change in the licensure and scope of the practice of dental assistants and dental hygienists. This is a piece of legislation that was up last year, ran out of time. So Senator Kolterman, the floor is yours.

SENATOR KOLTERMAN

(Exhibit 1) Thank you. Good afternoon Chairman Riepe and fellow members of the Health and Human Services Committee. My name is Senator Mark Kolterman, M-a-r-k K-o-l-t-e-r-m-a-n, and I represent the 24th District in the Nebraska Legislature. I am here today to introduce LB18, a bill that is very familiar, very similar to LB901 from last session, that deals with dentists, dental assistants, and dental hygienists. The bill advanced out of the HHS Committee with overwhelming support. Unfortunately, even with a Speaker Hadley priority designation, we ran out of time to pass the bill last year. We've been working hard during the interim with interested parties to compromise on a version that satisfies the stakeholders. LB18 incorporates some of the amendments from last year and makes a few technical changes, but it's mainly the same bill. Generally when someone comes to you with a scope-of-practice bill, you're first inclination is, run as far and as fast as you can away from the possibility. I believe that LB18 is different, and that's why I agreed to carry this bill on behalf of the Nebraska Dental Association, the Dental Assistants Association, and the hygienists. LB18 is a scope-of- practice bill, but this bill is an example of how scope-of-practice bills should work. As I mentioned, LB18 is the result of a tremendous amount of work on behalf of the dentists, dental assistants, and the dental hygienists. These parties have met for over six years, discussing and ultimately reaching an agreement about expanding the scope of practice from dental auxiliaries...for dental auxiliaries. The Nebraska Dental Association House of Delegates unanimously supported this effort; that's something you don't see very often, the profession promoting a scope-of-practice increase for their auxiliaries. Rather than wait for a piecemeal attempt at scope of changes over the next few years, the dentists, the assistants, and the hygienists all convened to discuss how to best provide care across the dental continuum. The goal is to create safe and quality care at the least cost and be able to allow Medicaid providers the ability to appropriately delegate functions to allow for more care, again at the least cost. Once some sort of consensus was reached, the dentists and the dental assistants took the proposed changes through the 407 process at the Department of Health and Human Services. Their application was approved at all three stages of the 407. The hygienists had a separate 407 that was not approved. I won't go into the detail about what is in LB18; Dr. Jessica Meeske, with the NDA, will do that. But I do want to give you a broad overview of what is in the bill. I have provided a spreadsheet that outlines the new responsibilities and duties included with this bill, and you should all have a copy of this. First, the bill leaves dental assistants as they currently exist in order to allow dentists who do not want to delegate responsibilities to function without any change. A new level of dental assistant is created, a licensed dental assistant with increased education requirements and increased duties. In addition, a licensed dental assistant with additional education and testing can apply to receive permits to perform expanded functions. Second, the bill increases the scope of practice for dental hygienists. Just like licensed dental assistants with additional education and testing, the licensed dental hygienists can apply to receive permits to perform additional expanded functions which, again, are outlined in the handout. Third, the public health dental hygienists have an increase scope of practice, as well. In a public health setting, again with education and testing, the licensed dental hygienist can perform additional tasks for seniors or children. These duties may be performed without supervision by a dentist. This team approach to the dental practice is an important step forward in providing the highest quality of service at the least cost to the patient. Again I want to commend all the parties for getting together and working on compromises to bring to the committee and to the Legislature. I want to make it clear that all the parties support this legislation; there's no opposition from the dental assistants, the dental hygienists, or the dentists. All of their concerns were worked out last year. Thank you for your support, and I'm happy to try and answer any questions you might have.

LB18

SENATOR RIEPE

Are there any questions from the committee? Thank you, Senator. You'll be here for the closing?

LB18

SENATOR KOLTERMAN

I will be.

LB18

SENATOR RIEPE

Okay. Any proponents, please.

LB18

JESSICA MEESKE

(Exhibit 2) Good afternoon. My name is Jessica Meeske; it's spelled J-e-s- s-i-c-a M-e-e-s-k-e, and I'm a children's dentist with practices in Hastings and Grand Island. I'm also chair of the Nebraska Dental Association's Medicaid Committee, and I'm a trustee with the American Academy of Pediatric Dentistry. I'm thrilled to be here and speaking in support of LB18. Allowing dental team members to do more to care for kids in our practice would have a huge impact on our ability to serve more underserved kids. Nearly 70 percent of patient visits in our practice are kids that are on Medicaid, and pediatric dentists tend to see a disproportionate amount of these kids. In Nebraska, only 52 percent of children who qualified for Medicaid in 2014 received any preventive dental visit: a cleaning; a sealant; just seeing a dentist. Because Medicaid covers nearly half the kids in our state and the demand to see more of those kids is now increasing, unfortunately the reimbursement is not. Allowing us to delegate those duties where a dentist's expertise is not needed allows us to be more efficient in how we deliver dental care. It's a model that medicine figured out decades ago. And the proposal that we've outlined maintains that the dentists have responsibility for all aspects of a patient's dental care, but it allows us to delegate the simpler procedures. As a member of the original task force that met on this issue for five years, I feel we have a good solution that makes sense for Nebraska. Part of my role on that task force was to compile all the research on patient safety, on quality outcomes, on cost efficiency. And I'm sure none of you have any reading to do at night, and I'd be happy to make that information available. Of course it has been summarized in the 407 report. So let me illustrate for you how this would work. Sue, who's a well-behaved, let's call her "Sits So Sweetly Sue," is a five-year-old who needs an amalgam filling, and she's had many good dental visits in the past, and we know Sue is a good helper at the dentist. As law is now, one of my hygienists would go over and place the "sleepy water," otherwise known as the numbing medicine, and then would explain how the procedure is going to work. She'd say: Dr. Meeske is going to come and use Mr. Whistle to scrub the sugar bugs off your teeth, and then she'll put a silver star, the filling, in its place. If this change comes into effect, I can go over and remove the decay, and then I can delegate placing a simple filling to one of my staff. Now this staff person has to have additional education, certification, in some cases licensure. Once Sue's filling is complete, I come over and check it to be sure everything looks good. Sue is a happy camper because she has done a great job, gets to pick out a prize. Sue's mom is happy because she was able to get a dental appointment in a timely manner, didn't have to wait for the doctor for every step. And this is a good thing because now walks in an emergency patient, a three-year-old who broke his front teeth at Head Start climbing on a chair. We're going to call him "Might Be A Little Monster Merv" (laughter). He will have to get a "prince crown" on his baby tooth with some "happy gas." Due to his young age and behavior, this requires the skill only of the dentist. Finally, there's economic value in this bill. Number one, it makes us competitive with our neighboring states, who we're losing staff to because the opportunities for career growth are greater there. Two, it gives dental assistants and hygienists a very viable career path because now they can do more and that increases their income potential. And three, if we can provide more access to dental care for Nebraskans, and particularly those that can't afford more extensive dental treatment, we're going to have a healthier population. Unfortunately, when you have significant tooth decay and gum disease, it's not just the dental costs. Often that spills over to much more expensive medical costs. And when we have a healthier population, our adults are going to miss less work and our kids are going miss less school due to dental-related illness. Thank you for considering advancing this bill. If passed, this bill will help dentists and their valued team members get more dental care to Nebraskans. I am very proud of the three organizations: the Dental Association, the Hygiene Association, and the Assistant's Association, who worked so diligently and thoughtfully to find a solution workable for all. I'd like to thank them and Senator Campbell, and we're happy to bring you this succinct and commonsense bill. Thank you, and I'd be happy to answer any questions.

LB18

SENATOR RIEPE

Thank you. Are there questions from the committee? I happen to have a question and that is...I'm sort of speaking...that if this is an access issue...and what's the pent up demand, if you will, in central Nebraska, for a pediatric-specific dentist?

LB18

JESSICA MEESKE

Sure, yeah. So it's a lot of different things. One is we just have more people in the rural parts of our state who don't have access to water fluoridation. We also don't have as many dentists. So we have some counties that have no dentist at all or are designated as underserved areas. And then also, when you see times where you're having to cut back on Medicaid, like with the state budget, you're going to sometimes see dentists that feel they're not able to see as much Medicaid. So we have long waits to get in our practice, long waits for surgery, and this is going to allow me to delegate some of the simpler things so I can do those more complex ones.

LB18

SENATOR RIEPE

Is your reimbursement from commercial or Medicaid then reduced by having a non-dentist take care of those?

LB18

JESSICA MEESKE

No, not as of yet.

LB18

SENATOR RIEPE

Oh, so there's no disincentive for you to hang on to this as a dentist?

LB18

JESSICA MEESKE

No, but it does allow me to be more efficient in seeing more kids that might have an insurance plan with lower reimbursement, as opposed to crowding them out with kids that have higher reimbursing plans.

LB18

SENATOR RIEPE

Very good. Senator Erdman.

LB18

SENATOR ERDMAN

Thank you for coming. My question is very straightforward. So if little Susie gets her tooth filled by your assistant, is the charge the same?

LB18

JESSICA MEESKE

Yeah, the charge is the same. Um-hum.

LB18

SENATOR ERDMAN

Okay.

LB18

SENATOR RIEPE

Okay. I remember you were here last year, and you have a daughter who is a star basketball player.

LB18

JESSICA MEESKE

I did last year, yeah.

LB18

SENATOR RIEPE

You did last year, okay.

LB18

JESSICA MEESKE

She's at Hastings College. Unfortunately she's injured right now, but she's watching on the live feed. She was supposed to be here today, but she had the flu. But I do have two interns I brought from Hastings College if I could introduce them.

LB18

SENATOR RIEPE

Please do.

LB18

JESSICA MEESKE

Okay, I have Kaitlyn Harvey and she is a sophomore predental student; she's from the North Platte area. And then I also have Mandy Amberg, who's a graduate of Lincoln North Star, also a sophomore predental student. And I've made sure that they have visited the professor/Senator Kuehn today, as well.

LB18

SENATOR RIEPE

Okay, and you have some stipulations that they have remain in central Nebraska when they graduate from dental school?

LB18

JESSICA MEESKE

They have to stay in central Nebraska, they have to be a great dentist, Medicaid provider; and I've pledged to mentor them throughout.

LB18

SENATOR RIEPE

So you have two mothers (laughter). Thank you very much for being here.

LB18

JESSICA MEESKE

Thank you so much.

LB18

SENATOR RIEPE

Are there other proponents, please? Welcome.

LB18

CYNTHIA CRONICK

(Exhibits 3 and 4) My name is Cynthia Cronick, C-y-n-t-h-i-a C-r-o-n-i- c-k, and I am a legislative cochair for the Nebraska Dental Assistants Association. My written testimony is on behalf of both myself and the other cochair, Crystal Stuhr, who is in the audience with us today. I've also handed to the clerk a written testimony from our president of the Nebraska Dental Assistants Association. I am pleased to be here today to speak in support of LB18. As a dental assistant of 45 years, and proudly I will say that, I would like to talk about the changes and duties this bill would mean for dental assistants and how that is beneficial. As you have seen, LB18 is structured with two tiers for dental assistant: a dental assistant and licensed dental assistant. This ensures that the current dental assistants do not lose their jobs or any of their duties with this bill. A dental assistant does not have to meet any new requirements to keep their job, and a dental assistant or a dentist does not have to change in any way how they currently practice. However, an assistant with the desire and ability to be a more productive team member has an opportunity with this bill to become a licensed dental assistant. After establishing baseline knowledge in their field through testing a dental assistant could take courses that would enable them to perform new duties such as: cementing a crown on a baby tooth, placing a patient on nitrous to relax them, or taking final impressions on which a denture, partial, crown, or bridge could be constructed. These courses would have education in both the classroom, laboratory, and clinical components to ensure knowledge and competency. Once a licensed dental assistant has established experience at this level, they could take further courses, as Dr. Meeske just talked about, to place a filling in a tooth that a doctor has removed the decay from or the old filling from. And these courses would start with the simplest fillings and, once those are mastered, then they would move on to the more complex. So as you can see, the structure of LB18 ensures that no dental assistants are displaced in any manner and that, as dental assisting duties advance, so does the level of education and experience. While this model came forth with the desire to improve how we treat our patients, it does have benefits for the dental assistants. The career paths that are created lead to self esteem, job satisfaction, and longevity, which is also a benefit for the practice and the patient. Dental assistants will be able to remain in their field and still advance in their career, and we will keep the talented ones, also a benefit to the patient and practice. Dental assistants will benefit from the education required for the duties and the continuing education that licensure will require, leading to lifelong learning and dental assistants current in their field, also a benefit to the patient and the practice. Dental assistants' earning potential will increase in proportion to their value to the practice and, most importantly, dental assisting will not be just a job; it will become a licensed profession. This is a concept near and dear to my heart and the hearts of dental assistants. I support LB18 because it will safely improve the efficiency of the delivery of dental care, it accomplishes this by allowing a dentist the flexibility to delegate those duties that they can safely delegate to assistants who are trained to do them, freeing the dentist up to do those procedures that only they can do, leading to office efficiency. This is a win-win-win situation: a win for the patient with increased access to quality care; a win for the practice with the flexibility to delegate; and a win for the dental assistant with the enhancements to the career of dental assisting. Thank you for your consideration of LB18. I would also like to acknowledge one other person that's here from our national organization, the American Dental Assistants Association. We do have our Eighth District trustee, Darlene Mundt, with us today.

LB18

SENATOR RIEPE

Okay.

LB18

CYNTHIA CRONICK

Thank you and I would be happy...

LB18

SENATOR RIEPE

Welcome, Darlene.

LB18

CYNTHIA CRONICK

I would be happy to take any questions if you have any.

LB18

SENATOR RIEPE

Thank you. Are there questions from the committee? Yes sir, Senator Williams.

LB18

SENATOR WILLIAMS

Thank you Chairman Riepe, and thank you for being here today. And thank you for your professional testimony. Could you walk me through a little bit the time frame under which the training would be given and how they would do that, whether that's course time, whether it's on-line training?

LB18

CYNTHIA CRONICK

This will be established more likely through rules and regulations; it isn't strictly spelled out. But in the 407...and in the intent of this is to have both classroom training, and parts of it might be on-line, especially to outreach to the western part of the state; that's a very efficient way to do that. However, it cannot all be done on-line, because we'll have laboratory and clinical components where there would be hands-on, on models and mannequins and then hands-on on patients. And this is structured so that a dental assistant is not going to try to bite off this entire chunk of duties all in one. As you heard me say, we've done it in a tiered process with steps, so that you master skills and then you take further courses to move forward. And I hope that answered that for you.

LB18

SENATOR WILLIAMS

It does, and as I'm understanding--correct me if I'm not understanding this correctly--if you started by taking the course on using the nitrous...

LB18

CYNTHIA CRONICK

Um-hum.

LB18

SENATOR WILLIAMS

...would, when you completed that course, would you then be, I'll use the term, certified to do that process?

LB18

CYNTHIA CRONICK

Correct, the...

LB18

SENATOR WILLIAMS

And then you'd continue down this continuum, moving that way.

LB18

CYNTHIA CRONICK

Correct, I believe you have a good grasp on that.

LB18

SENATOR WILLIAMS

I think the fiscal note suggests that there might be 1,650, roughly, of these licenses issued; that's the estimate. Do you have any thoughts on whether those will be spread evenly around the state?

LB18

CYNTHIA CRONICK

I would say they'll probably be spread into...in proportion to the existing workforce, because that what's we're utilizing as an existing workforce. So it will have to come forward from the assistants that are currently in practice.

LB18

SENATOR WILLIAMS

Right.

LB18

CYNTHIA CRONICK

And this won't be for everyone. Everyone won't have the desire to do these duties, and so for those that do, it does offer that opportunity. For dentists that want to utilize this and see this as a plus in their practice, they're probably going to encourage staff members and guide staff members who they feel have the ability to move forward with this.

LB18

SENATOR WILLIAMS

But again, there's no requirement of that on the part of the dentist or of the assistant.

LB18

CYNTHIA CRONICK

Correct, correct...the tiered approach (inaudible).

LB18

SENATOR WILLIAMS

Are you going to be 1,651?

LB18

CYNTHIA CRONICK

I will be right up there at the beginning.

LB18

SENATOR WILLIAMS

Okay.

LB18

CYNTHIA CRONICK

It's a lifelong goal of mine, and I'm hoping to see this happen. And it's a little...I'm saddened because it's a little late in my career for me, but I...if this bill goes through, I will be proud to be a licensed dental assistant.

LB18

SENATOR WILLIAMS

Thank you.

LB18

SENATOR RIEPE

Are there other questions? A question that I have is, do you see, over time, that the...all of the dental assistants will then be licensed, that it will be a grandfather clause kind of a movement? Or is...

LB18

CYNTHIA CRONICK

There's no real grandfather clause, except that the current dental system is left in place. And then those with the desire to do more would move forward with this. And I don't foresee that it's for everyone and that everyone would like to do this. I don't foresee that every practice will utilize this, so I don't think we'll ever see, in the very near future, every dental assistant licensed.

LB18

SENATOR RIEPE

Okay.

LB18

CYNTHIA CRONICK

But that's an opinion and, looking at some of the states that have done similar things, it's usually a percent; it's usually not the entirety.

LB18

SENATOR RIEPE

Um-hum. Well, we all have opinions and we get a lot of opinions, and we appreciate opinions because it's a reflection of thought. Usually those are with some time spent in the industry. So thank you very much.

LB18

CYNTHIA CRONICK

You're welcome.

LB18

SENATOR RIEPE

Are there other proponents that would like to speak? Is there anyone here that's going to talk on sleepy water? Was that what you said? Okay. Go ahead, please.

LB18

KAREN FIALA

(Exhibits 5 and 6) Good afternoon Chairman Riepe and members of the Health and Human Services Committee. My name is Karen Fiala, K-a-r-e-n F-i-a-l-a, and I'm here today, as the president of the Nebraska Dental Hygienists' Association, to testify in support of LB18. As Senator Kolterman mentioned earlier, the process for putting this bill together has literally taken the better portion of a decade and it is the result of all parties giving and compromising. And I want to thank Senator Kolterman for his dedication to this effort. And a little background on me: I am a graduate of UNMC's College of Dentistry Dental Hygiene Program, with my bachelor's of science in dental hygiene. And I grew up and currently live and practice in Columbus, Nebraska. And I've been in practice for about ten years almost. And I have a couple of documents for you guys to reference. And the first document is a side-by-side comparison of what licensed dental hygienists in Nebraska can do today and what licensed dental hygienists, public health dental hygienists, and expanded-function dental hygienists would be able to do following the passage of LB18. We are excited to grow our profession and to make hygienists more employable and to have the potential to provide much needed services to patients in Nebraska. We do, however, have just a couple of concerns regarding the education and experience requirements in this bill, and those concerns are twofold: the first would be that students finishing their schooling will be required to wait a year before being able to perform these duties or procedures and two, that if the 1,500 hours of education does not fulfill the requirements of LB18, then dental and dental hygiene programs are not obligated to provide the education required by LB18. The Commission on Dental Accreditation, or CODA, only requires dental programs to prepare entry-level dental hygienists. And on the second page you have is a small outline of what our current state programs offer in the years of the dental hygiene program and the hours that are spent didactically, clinically, and in laboratory. And anything else we do outside of the school is additional hours of practice. The NDHA believes that, upon graduation from an accredited Nebraska dental hygiene program, that Nebraska students will have completed enough didactic, clinical, and lab hours to meet the 1,500-hour requirement of LB18 and should be able to apply for expanded duty license. We would like our future graduates to have been instructed in these areas required to be an expanded function dental hygienist, to be able to perform these duties upon completion of their degree and successful completion of the appropriate testing. And we will ask that the Board of Dentistry and that the local dental hygiene schools work together so everyone can benefit from the passage of LB18. Thank you. Any questions, please.

LB18

SENATOR RIEPE

Thank you very much. Questions from members of the committee? Hearing none, thank you very much for being here.

LB18

KAREN FIALA

Thank you.

LB18

SENATOR RIEPE

Additional proponents. Seeing none, any opponents? Seeing none, are there any neutral? Tyler, can you...do we have letters that have been submitted, first in support?

LB18

TYLER MAHOOD

(Exhibits 7-9) Yes, we have a letter from Matt Litt, who represents Americans for Prosperity, in support. And then we also have a letter that came in neutral from Diane Jackson, who is with the State Board of Health.

LB18

SENATOR RIEPE

And no one in opposition?

LB18

TYLER MAHOOD

There's no opposition letters.

LB18

SENATOR RIEPE

Okay. Senator Kolterman, would you like to close, please?

LB18

SENATOR KOLTERMAN

Thank you, Senator Riepe. You can see why it's so easy to work with such a good group of people. They're all pointing in the same direction, all want the same type of services for their patients, and we can be thankful that we have these dedicated professionals in our state. With that, I would ask that, in Exec, we advance this tomorrow. And I'd entertain any questions you have.

LB18

SENATOR RIEPE

Any questions? Senator Williams.

LB18

SENATOR WILLIAMS

Thank you, Chairman Riepe. Senator Kolterman, the last testifier, Ms. Fiala, brought up two concerns; they still testified clearly in support of the legislation. Have those concerns been looked at through this process?

LB18

SENATOR KOLTERMAN

Yes, they have, and they did not, as I recall, they did not pass the 407, but we did agree on the bill as it...that is proposed. And it will meet their...they will meet their requirements.

LB18

SENATOR WILLIAMS

Okay, thank you.

LB18

SENATOR RIEPE

Any other questions? If not, that concludes the hearing on LB18. And thank you, Senator Kolterman.

LB18

SENATOR KOLTERMAN

You're welcome.

LB18

SENATOR RIEPE

Our next bill in front of us today, and thank all of you that were here specifically for LB18; and we appreciate it very much. Our next hearing will be on LB19, again with Senator Kolterman, and it is a change requirements for the practice of acupuncture. Senator, you're on.

LB19

SENATOR KOLTERMAN

Good afternoon again, Senator Riepe and fellow members of the Health and Human Services Committee. My name is Senator Mark Kolterman, M-a-r-k K-o-l-t- e-r-m-a-n. And I represent the 24th District of the Nebraska Legislature. I'm here today to introduce LB19, a bill that changes requirements for the practice of acupuncture. This is the same bill that former Senator Nicole Fox introduced last year, advanced unanimously out of this committee and was designated a Speaker priority bill. Unfortunately, we ran out of time and were unable to debate it on General File. LB19 is a codification of a 407 report dealing with referrals to and from licensed acupuncturists. Currently under state statute, an individual seeking services from a licensed acupuncturist must first, within a 90-day period prior to visiting the acupuncturist, obtain a referral from a medical doctor and present that referral to the acupuncturist. LB19 is the result of a 407 review process during which the Board of Health reviewed the current 90-day referral process to determine if the referral scheme was actually...served any viable or necessary purpose in terms of services provided and/or safety of the patient. Upon review, it was determined that there was no public safety interest served by maintaining this requirement in statute. As such, the Board of Health and the state chief medical officer recommended that the 90-day referral requirement be removed from statute and replaced with the standardized referral language used in other states. Rather than requiring the prereferral from a doctor, if adopted as presented in both the 407 report and LB19, the licensed acupuncturist would now be required to refer patients they may see that present to them, on initial examination, with problems or symptoms outside or beyond their scope of area of training. The new referral language in statute will read as follows: "An acupuncturist licensed under the Uniform Credentialing Act shall refer a patient to an appropriate practitioner when the problem of the patient is beyond the training, experience, or competence of the acupuncturist." This new language is standardized referral language that has been put in place in other states, such as Minnesota. The Board of Medicine has reviewed and recommended the placement of the referral language in statute, along with the removal of the 90-day prereferral from a doctor. LB19 simply codifies, in statute, the findings of the 407 report dated February 14, 2014. Thank you, and I'm happy to answer any questions you might have.

LB19

SENATOR RIEPE

Thank you, Senator Kolterman. Any questions from the committee? Hearing none, and we know that you'll be here for the closing, right?

LB19

SENATOR KOLTERMAN

Thank you.

LB19

SENATOR RIEPE

Okay, thank you. Any proponents?

LB19

DONNA HUBER

Hello. My name is Donna Huber; I am a licensed acupuncturist and owner of Thirteen...

LB19

SENATOR RIEPE

Would you spell your name, ma'am, please.

LB19

DONNA HUBER

Oh, yes, I'm sorry. D-o-n-n-a H-u-b-e-r. I had it on top to do that anyway.

LB19

SENATOR RIEPE

Thank you.

LB19

DONNA HUBER

(Exhibit 1) Those dentists are going to be a hard act to follow with their humor. On behalf of the Nebraska licensed acupuncturists, we'd like to thank Senator Kolterman for introducing LB19 and to thank the committee and Chairman Riepe and for hearing us today. I am the owner of Thirteen Moons Acupuncture in Omaha and have been in practice for 14 years. I am the former president and former treasurer of the Nebraska Acupuncture and Oriental Medicine Association. I founded our small association eight years ago and have been working on the statute language change, in some form or fashion, for about 13 years. In 2013 we went through the 407 review process. The reports are all included in your packet there. In spite of being told that we would not likely get "yes" recommendations, we did from the Technical Review Committee, the Board of Health, and the chief medical director. We are proud of our efforts and subsequent "yes" recommendations. By spotlighting our high level of education, skill, training, and our stringent national competency measures, we effectively showed that we are the experts in our field and that we shared with the committee concerns for public safety. We believe, given our credentials, the public should have direct access to our services. Acupuncture is a safe form of healthcare when administered by the highly-trained hands of a state-licensed, nationally-certified practitioner. A referral or doctor visit requirement does not increase the longstanding record of safety of acupuncture. Further, the imposition of a referral requirement removes the cost effectiveness by creating an entrance fee to the medicine. Two of the questions that came up during the 407 review is whether this was related to insurance coverage or if this was part of a so-called turf war. Neither is true. This is not about insurance coverage, nor is it about turf. This is standard language, adopted in most other states, and we are trying to make uniform. One deniable fact that must guide Legislature above all else--physician referrals do not increase public safety. That is why they have been largely eliminated because such barrier provisions only decrease access, which is counter to public interest. The safety irrelevance of a referral requirement has been proven for over two decades. We are committed to making acupuncture accessible, affordable and, above all, safe to the people of Nebraska and look forward to seeing this bill passed so that we can all get back to work, doing what we do best-- caring for our patients. I have personally put a lot of blood, sweat, and tears into this language change, and I am proud of my efforts and the efforts of our growing association that have landed us here. I just really want everyone to learn and understand the depth and breadth of traditional Chinese medicine, as I feel it holds a key to our ever growing issues of ill health in this country. It was born under the observation of humans in nature, how best to function in our surroundings. It is a preventative medicine and seeks to get to the root of problems. We are in a unique position to provide great help and relief to our patients, the community, and the system. It has its limitations, just as our biomedicine model does but, working together, we can do great things. Thank you, and I am happy to answer any questions that you may have.

LB19

SENATOR RIEPE

Thank you very much. Are there any questions from the committee? I have two.

LB19

DONNA HUBER

Yes, sir.

LB19

SENATOR RIEPE

One would be is, do you, in your association, do you have a peer review process?

LB19

DONNA HUBER

A peer review process...

LB19

SENATOR RIEPE

Peer review so that, I mean, to assure some oversight among your...to keep the integrity and the quality of the acupuncture?

LB19

DONNA HUBER

Of our...just of the association?

LB19

SENATOR RIEPE

No, just of the services provided.

LB19

DONNA HUBER

Yes, we have very stringent competency measures. We are required to have 50 continuing education units every two years to maintain our license in the state of Nebraska, and then for our national certification, which is not...we don't have to continue our national certification. I do, so every four years I have to have 60 credit hours for my national recertification.

LB19

SENATOR RIEPE

Um-hum.

LB19

DONNA HUBER

But for the state of Nebraska, it's 50 every two years.

LB19

SENATOR RIEPE

Um-hum. While I think didactics is important, I think I'm even more concerned, though, about actual hands-on clinical performance, if you will. And I don't know whether you have any oversight that people have to, you know...I'm even concerned about sterile technique and all the stuff that doesn't go with book learning; it goes with quality control.

LB19

DONNA HUBER

Right. So part of our training before we can even be licensed in the state of Nebraska is to be certified by our national certification, which is the NCCAOM. They have-- they're tab number two in here. We sit for rigorous exams, not unlike medical exams, and part of what we also do is a clean-needle technique class and certification that we have to complete prior to taking that test, or along the same lines, and then...but it also was required by the state of Nebraska. So we have that measure in place.

LB19

SENATOR RIEPE

Do most of your practitioners practice in solo or in some group, e.e. (phonetic), albeit maybe two?

LB19

DONNA HUBER

Both...we have people who work together, and they...you know, there have been a total of 52 license issued in the...since 2001, when the original law was passed. And people have come and gone throughout that time, and one of the reasons for that is because it's somewhat of a difficult state and an expensive state to practice in with our...how rigorous the competency measures are and the continuing ed units that we have to take. Often we have to travel to do that, although now there are starting to be more and more on-line. But...I'm sorry, what was the...what question do you want me to answer?

LB19

SENATOR RIEPE

Well, my question was, is if most of your people practiced in solo practice, because my bias is that, whether it's acupuncture or medicine or anything else, solo practitioners have a tendency to drift, if you will, from oversight, because there is no one there saying: that's not the way we do it. So...

LB19

DONNA HUBER

I...

LB19

SENATOR RIEPE

I get nervous with solo practitioners; that happens.

LB19

DONNA HUBER

Of acupuncturists or medicine or chiropractic, any?

LB19

SENATOR RIEPE

In anything...anything that has to do with patient clinical care.

LB19

DONNA HUBER

Well, we have a very active association. It's a small one because there are only about 20 currently actual licensed acupuncturists in the entire state of Nebraska. We are the ones who have four-year, 3,000-hour master's degrees in Eastern medicine and the practice of the medicine.

LB19

SENATOR RIEPE

Again, I think didactics important; I'm less concerned they're book learners and they're actual good practitioners.

LB19

DONNA HUBER

Right, and I...

LB19

SENATOR RIEPE

And the second question that I have, excuse me, is, do you currently or do you anticipate seeking Medicaid reimbursement?

LB19

DONNA HUBER

No, we are not interested in that at this time.

LB19

SENATOR RIEPE

Okay, okay. Thank you.

LB19

DONNA HUBER

Thank you.

LB19

SENATOR RIEPE

Any other questions? Senator Williams, yes.

LB19

SENATOR WILLIAMS

Thank you, Chairman Riepe. Just a point of clarification so I understand, I think you said there were 52 licensed, but about 20 currently practicing. Where else can you get acupuncture done in the state other than with one of your licensed people?

LB19

DONNA HUBER

The...prior to the law being passed in 2001, chiropractors, medical doctors, and, I do believe, dentists actually were allowed, and are still allowed, to do acupuncture within their scope of practice. And, you know, nationally and also in the state of Nebraska, there are physical therapists who are doing something that they call dry needling, which is, essentially, acupuncture. And so part of the reason that we were interested in doing this is because we are the ones with the oversight, the education, the skill, competency measures...

LB19

SENATOR WILLIAMS

So in Nebraska today, are there chiropractors that are still providing acupuncture services?

LB19

DONNA HUBER

Yes, there are.

LB19

SENATOR WILLIAMS

Because it comes under their scope of practice as a chiropractor, so...

LB19

DONNA HUBER

Somehow it...that is correct. And they actually don't have...

LB19

SENATOR WILLIAMS

That clears up what I was...my...yeah. Thank you.

LB19

DONNA HUBER

Yeah, okay.

LB19

SENATOR RIEPE

Is that all under the same standards?

LB19

DONNA HUBER

No, actually they don't have to have...their statute does not have any requirement to have education. There's no oversight, no competency measures, they don't do continuing education units, so no.

LB19

SENATOR RIEPE

Okay.

LB19

DONNA HUBER

Some states actually will have a 100-hour or a 300-hour requirement for nonlicensed acupuncturists to provide that.

LB19

SENATOR RIEPE

So for the consuming public, it leaves some question, in terms of...

LB19

DONNA HUBER

That is exactly right, which is why we would like to be autonomous, because we feel that we are the experts in this field of putting needles in people's bodies. We know we have the training, we have the skill, we have the education behind it.

LB19

SENATOR RIEPE

Sleepy water sounds much more attractive.

LB19

DONNA HUBER

I know, right?

LB19

SENATOR RIEPE

Thank you very much.

LB19

DONNA HUBER

Thank you.

LB19

SENATOR RIEPE

Are there other questions? Hearing none, we will...other, are there other proponents?

LB19

DONNA HUBER

There's one other, yes.

LB19

SENATOR RIEPE

Thank you.

LB19

DONNA HUBER

Thank you.

LB19

MAUREEN FEENEY

Hello.

LB19

SENATOR RIEPE

Welcome.

LB19

MAUREEN FEENEY

(Exhibit 2) Thank you for seeing us today; we appreciate it. My name is Maureen Feeney, M-a-u-r-e-e-n, Feeney, F-e-e-n-e-y, and I am the current president of our association. I am also a registered nurse, and I have my own practice also, in Omaha. I've been in practice for almost five years. And I just have a letter from a doctor that the majority of the licensed acupuncturists work with; her name is Dr. Victoria Maclin. She's the medical director of Heartland Center for Reproductive Medicine. And I just would like to read her letter and answer any questions, if you have any, if that would be all right with you.

LB19

SENATOR RIEPE

Please go forward.

LB19

MAUREEN FEENEY

All right: It is with pleasure that I submit this letter of support for Nebraska Acupuncture and Oriental Medicine Association and LB19 to amend Section 38-2058, to change requirements for the practice of acupuncture. Specifically the requirement that in order for an licensed acupuncturist to practice acupuncture, the patient must be referred by an MD or a DO. The implication of this referral requirement is that the MD or DO is the gatekeeper determining if acupuncture is an appropriate intervention. This is problematic considering that acupuncture is not a standard part of an MD or DO's training curriculum. It is unreasonable to expect that one with no training in or understanding of a discipline can be the gatekeeper of its application. On the other hand, an L.Ac is required to have a master's degree in acupuncture and oriental medicine, certification from the National Certification Commission for Acupuncture and Oriental Medicine and is required to accumulate 50 continuing education hours every two years to maintain their license in the state of Nebraska. Indeed, there is no one more qualified to determine appropriate patient selection for acupuncture than one who meets the rigorous educational and certification criteria to be an L.Ac. It is incumbent upon any healthcare professional to understand the efficacy and appropriate application of their practice as well as the limitations. Depending on the specific condition, acupuncture may either a primary or ancillary intervention. The L.Ac's rigorous training is aimed toward allowing them to make appropriate decisions when to treat autonomously versus when to refer or collaborate. I am a reproductive endocrinologist and have had the opportunity to collaborate with L.Acs in our community, treating patients with infertility. It has been my experience that these professionals keenly recognize when the necessary interventions are within their scope and when referral to a gynecological or reproductive endocrinologist is indicated. I also refer to them for the ancillary benefits of their interventions to the medical and operative treatments I provide. We are both well trained in our disciplines and know when autonomy or collaboration is appropriate. I am very hopeful that LB19 is passed. It is time for licensed acupuncturists to receive the respect and autonomy that their professional training, commitment to continuing education and excellence deserves. Respectfully submitted, Dr. Victoria Maclin. So that is a letter from one of our doctors we work with. And does anyone have any other questions?

LB19

SENATOR RIEPE

Are there any questions of the committee?

LB19

MAUREEN FEENEY

Thank you so much.

LB19

SENATOR RIEPE

Okay. Thank you very much. Any additional proponents? Ms. Robak?

LB19

KIM ROBAK

(Exhibit 3) Good afternoon. Senator Riepe, members of the committee, my name is Kim Robak, K-i-m R-o-b-a-k. I'm here today on behalf of the Nebraska Medical Association in support of LB19. We're pleased to be here to support this effort. The acupuncturists went through the 407 process. They received green lights along the way and, in many instances, medical doctors do refer to acupuncturists for certain types of treatment. In this instance, many members of the public were unaware that they needed a physician to provide a prescription before going to an acupuncturist and, as a result, the process is now being simplified and individuals are able to go to an acupuncturist without having a prescription from a physician. You do have a letter, I think you will have a letter in front of you that was sent on behalf of the Nebraska Medical Association, indicating that they do support the bill, especially with lines 13-16 of the bill that state that an acupuncturist should refer to a medical practitioner when treatment is beyond the scope or the training or the competency of the acupuncturist. With that said, I'd be happy to answer any questions.

LB19

SENATOR RIEPE

Thank you very much for being here. Are there questions from the committee? Hearing none, thank you very much. Are there other proponents? Any opponents? Anyone testifying in a neutral capacity? Okay. Tyler, do we have some letters, if you will?

LB19

TYLER MAHOOD

(Exhibits 4-6) Yes, I have two letters again. One is from Matt Litt of Americans for Prosperity, a letter of support, and one is from Diane Jackson, State Board of Health, with a neutral position.

LB19

SENATOR RIEPE

Okay. With that, Senator Kolterman, would you like to close? You're going to waive closing, so that concludes this hearing. Thank you very much; we appreciate that. Our third and final hearing this afternoon will be LB33 with Senator Ebke, and the title on this is the charge (sic: change) fee (sic: fees) for multiple copies of death certificates. So Senator Ebke, thank you for being here and please proceed.

LB33

SENATOR EBKE

(Exhibit 1) Thank you, Chairman Riepe and members of the Health and Human Services Committee. My name is Laura Ebke, L-a-u-r-a E-b-k-e. I represent Legislative District 32. I will promise you that this will be your shortest bill of the day. My intention with this bill was to consider specifically how much fees to obtain a death certificate should be and, more importantly, whether our state policy should be to make money on the fees charged or to look out for the citizens of the state and to provide a service. I believe that there is some room for us to make an adjustment on the cost of the purchase of a death certificate. The current fee is $16 per copy, regardless of when they're ordered. So if you order...if you go in and order eight copies of a death certificate all at once, you're going to pay $128, if my math is right. A constituent who needed to get eight copies brought this to my attention. More and more verification processes are requiring such documents, so if you have someone pass away, you need to--and you're helping to settle the estate or you're a spouse or you're a family member that needs copies--you need to go get a big chunk of death certificates. If you've ever had to deal with an estate settlement, you know just how quickly those costs can rise in obtaining all of the necessary documents. That said, we've had some confusion with our original intent. And the draft from the Revisor's Office that was introduced as the bill, as well as input from the Fiscal Office, has given me reason to ask that, at this point, this be held in committee or IPPed, as all the entities involved work out a better long-term solution that will be provided in a new version of the bill that I'll bring next year. I'd be happy to take any questions if you've any (laughter), or I'll let you go home.

LB33

SENATOR RIEPE

Thank you very much. Are there any questions? Senator Kolterman.

LB33

SENATOR KOLTERMAN

I just have a general comment.

LB33

SENATOR EBKE

Yeah.

LB33

SENATOR KOLTERMAN

As a person that utilizes a lot of death certificates in my practice, it is overwhelmingly expensive to get them, and it doesn't make a lot of sense that it requires $16 per certificate.

LB33

SENATOR EBKE

It doesn't make a lot of sense, especially...and we've streamlined things last year, I believe it was, we streamlined things so that doctors now have to input the death certificates into a digital format.

LB33

SENATOR CRAWFORD

Yeah.

LB33

SENATOR EBKE

It's easy to call it up. You know, the question is whether or not eight pieces of paper with a stamp on them that says it's official business should cost $128. And so I think that's something that we need to take a look at, going into the future.

LB33

SENATOR RIEPE

Senator Erdman.

LB33

SENATOR ERDMAN

Thank you, Chairman Riepe. So I'm a newbie, so tell me what the problems are and why we need to go forward and postpone it a year.

LB33

SENATOR EBKE

Sure. There was some confusion about whether or not this was to apply to all types of vital statistics; that was one of the issues. And both the Fiscal Office and the Drafter's Office--we just had some miscommunications. It would be easy enough and we've offered--we have a version--an amendment that could clarify some of this. I don't have any objection, if the committee is so inclined, to go ahead and amend the bill. You know if there's a way to go ahead and do that, that would make it acceptable to the committee, if you want to go ahead and make those changes. I just think that this is kind of a...philosophically we need look at whether or not we need to be charging this much for these vital records.

LB33

SENATOR ERDMAN

So follow up then. In my prior experience as a county commissioner, we would just make the necessary changes and move on. And we didn't kick the can down the road; we dealt with those issues as they came to us. And I guess it doesn't make any sense to me that we're going to kick this down the road another year. And as Senator Kolterman addressed the fact that it's still going to cost those people that are getting death certificates more money. So if we can make an adjustment to help those people, I believe that's what we're here to do. That's my thought on this and maybe that's how we do it here...we kick the can down the road, maybe got to have an interim study or a task force or something else and, consequently, that doesn't sound like common sense to me. So I throw that out there.

LB33

SENATOR EBKE

I'm absolutely fine with moving it and, like I said, I do have a white copy amendment that would clarify at least some of the issues. And I would encourage legal counsel, if you want to take a further look at it, to go ahead and do that, as well. This is...I'll keep one copy. This would change...this was brought...just help me out here, Brandon. Who sent this to us?

LB33

BRANDON BENSON

It's from the drafters.

LB33

SENATOR EBKE

Yeah, from drafters, to try to clarify some of this. I'm not sure if we actually clarified anything with this amendment or not, and that's why we were under the gun; we didn't want to necessarily confuse things even more. But if it's the committee's desire to go ahead and move this, I'm all for it.

LB33

SENATOR RIEPE

I'm sensing, Senator Erdman, you're now volunteering to head up an interim study (laughter). You have the mic, Senator.

LB33

SENATOR ERDMAN

Thank you so much. You are so correct; you're pretty perceptive. But, you know, I'm not...I don't know how this works here in the committee, and I'm just one person on the committee so don't assume that I'm speaking for the committee, but if we can go forward...if we can hold this until some further research is done on their behalf, so we can make an amendment to it. I don't know if that's possible, but I'm not in favor of kicking down the road.

LB33

SENATOR EBKE

And there's certainly the option of committee amendments. You know, we included, as sort of an arbitrary number, $16 for the first six, I believe it was. And then $5 for every one beyond that, as long as they were ordered all at once. And that was kind of the key, from our standpoint. You know, I don't know if that's the right number or not. So we can do some more research; if it's the committee's will, we'll be happy to do that. I was going to...if the committee doesn't want to deal with this though, I'm happy to do the work outside of the session time and we'll bring it back. So...

LB33

SENATOR RIEPE

Senator Kolterman.

LB33

SENATOR KOLTERMAN

I'd like to see you do the work.

LB33

SENATOR CRAWFORD

Um-hum.

LB33

SENATOR EBKE

Thanks.

LB33

SENATOR KOLTERMAN

I mean, seriously, I mean when vital statistics...I assume we're talking about birth certificates, death certificates, and marriage licenses.

LB33

SENATOR EBKE

Marriage licenses, yeah.

LB33

SENATOR KOLTERMAN

I just think it's ludicrous to pay that kind of money, because all they're doing is putting a stamp on it...

LB33

SENATOR EBKE

Exactly, yeah.

LB33

SENATOR KOLTERMAN

...and they're running it through a machine.

LB33

SENATOR EBKE

Right.

LB33

SENATOR KOLTERMAN

And it doesn't cost you $16 every time you do that.

LB33

SENATOR RIEPE

I always find it troubling to talk about marriage and death in the same sentence, but I guess that's, oh, just the way we deal (laughter). Yes, Senator Linehan.

LB33

SENATOR LINEHAN

Birth certificates the same?

LB33

SENATOR EBKE

Well, we looked at it...when we started out this was specifically death certificates.

LB33

SENATOR LINEHAN

(Inaudible) deaths.

LB33

SENATOR EBKE

And then, as the drafters worked on it, they're interpreting it as all of the vital statistics, including birth certificates and marriage certificates. And that's where we got a little bit tied up.

LB33

SENATOR LINEHAN

That's where the money exploded?

LB33

SENATOR EBKE

Yeah.

LB33

SENATOR LINEHAN

The fiscal note.

LB33

SENATOR EBKE

Yeah.

LB33

SENATOR RIEPE

Okay. Senator Crawford.

LB33

SENATOR CRAWFORD

Thank you, Chair Riepe, and thank you, Senator Ebke. I guess I don't concur that we'd be happy to have more work on it during the session, as opposed to waiting...

LB33

SENATOR EBKE

Okay.

LB33

SENATOR CRAWFORD

...if it's, if we can fix it with amendments. And I guess on that front, too, I would just ask if there was a reason for focusing just on death certificates?

LB33

SENATOR EBKE

Because that's what was brought to me.

LB33

SENATOR CRAWFORD

Okay. That's...okay, that was just the issue.

LB33

SENATOR EBKE

And then, and in point of fact, that's, I think...

LB33

SENATOR KOLTERMAN

The most (inaudible).

LB33

SENATOR EBKE

...that's the thing that you use the most of...

LB33

SENATOR CRAWFORD

Okay.

LB33

SENATOR KOLTERMAN

Um-hum.

LB33

SENATOR EBKE

...that you know, if somebody dies when you're settling an estate...

LB33

SENATOR KOLTERMAN

There's trouble.

LB33

SENATOR EBKE

...it goes, those death certificates go everywhere, for insurance and (inaudible), all sorts of things, so...

LB33

SENATOR CRAWFORD

Right. Was there any...I think you said before, but just to clarify and for the record and so that I understand, the idea of six and $16: was there...

LB33

SENATOR EBKE

There's not a magic number for us.

LB33

SENATOR CRAWFORD

Okay.

LB33

SENATOR EBKE

And that was the other piece of it. You know, what is the right number? And so we really need...this was brought to us kind of late.

LB33

SENATOR CRAWFORD

Um-hum.

LB33

SENATOR EBKE

And we didn't, we weren't able to contact the appropriate folks to find out what is your actual cost, which I think is important to know.

LB33

SENATOR CRAWFORD

Yes.

LB33

SENATOR EBKE

What is the actual cost to the counties or to the state or, you know, to actually process these? I don't think it's $128, you know. But it's probably something more than $5, so...

LB33

SENATOR CRAWFORD

So are you willing to contact those stakeholders, identify costs, get that information to the committee?

LB33

SENATOR EBKE

We can certainly work on that, if that is the wish of the committee.

LB33

SENATOR CRAWFORD

Thank you.

LB33

SENATOR RIEPE

Senator Linehan, do you have something?

LB33

SENATOR LINEHAN

Just one more question.

LB33

SENATOR EBKE

Sure.

LB33

SENATOR LINEHAN

When you do all this extra work, can you find out how long it's been $16? I mean, has it been $16 for...

LB33

SENATOR EBKE

It's been four years?

LB33

BRANDON BENSON

Yeah, 2014, I believe...LB994.

LB33

SENATOR LINEHAN

Okay, so it has kept up with inflation, so to speak. Okay.

LB33

SENATOR EBKE

Yeah.

LB33

SENATOR RIEPE

A question I would have...it's a tough year. It appears that there's lost revenue out of it, so that presents a fiscal note.

LB33

SENATOR EBKE

Right.

LB33

SENATOR RIEPE

Can you help us out on that?

LB33

SENATOR EBKE

I'll try. No, you know the fiscal note...I'm not sure that you can classify this as true lost revenue...

LB33

SENATOR WILLIAMS

You can, if it will work.

LB33

SENATOR EBKE

...because this isn't money that's automatically coming in anyhow. You don't know how much is going to come in to begin with, so it may be a stretch.

LB33

SENATOR CRAWFORD

It's cash.

LB33

SENATOR EBKE

But I'm not going to argue with the Fiscal Office about it, so...

LB33

SENATOR RIEPE

I just know that everything is sensitive about it.

LB33

SENATOR EBKE

Everybody is sensitive to the money.

LB33

SENATOR RIEPE

That's very much so. Are there other questions? Hearing none, but while I have you at the mic, I guess there may not be other proponents or opponents. Are you aware of any opponents that would push back on this?

LB33

SENATOR EBKE

Certainly the folks who process the vital statistics are probably the ones most likely to oppose. I don't know if anybody is here. I don't think so.

LB33

SENATOR RIEPE

Yeah. I was just concerned that you might waive the end and we'll regret it.

LB33

SENATOR EBKE

Yeah.

LB33

SENATOR LINEHAN

Just...

LB33

SENATOR RIEPE

Okay. Senator Linehan.

LB33

SENATOR LINEHAN

I'm sorry.

LB33

SENATOR RIEPE

Go ahead.

LB33

SENATOR LINEHAN

Because I also don't know this. So does the money that whoever processes gets...goes to the General Funds, or do they get to keep the pocket of money? Does it affect their bottom line?

LB33

SENATOR KOLTERMAN

Sure.

LB33

SENATOR WILLIAMS

Yes.

LB33

SENATOR EBKE

Yes.

LB33

SENATOR LINEHAN

Okay, they keep the fees.

LB33

SENATOR WILLIAMS

It's their budget, yes.

LB33

SENATOR LINEHAN

Okay.

LB33

SENATOR KOLTERMAN

Their budget.

LB33

SENATOR LINEHAN

Ah, okay. That makes...

LB33

SENATOR RIEPE

Okay, any other questions? Thank you very much for being here and opening for us. We'll ask you to close here, if you choose. Are there any opponents that...or proponents that wish to speak? Hearing none, any opponents? Any neutrals? Any letters?

LB33

TYLER MAHOOD

(Exhibit 2) Yes, I did have one from a Shawn Renner of the...he's with Media of Nebraska, Inc., and he sent in a letter in support of the legislation.

LB33

SENATOR RIEPE

Okay. Thank you very much. Senator Ebke, do you choose to waive? You do. Thank you very much; that concludes this hearing, and it concludes our work for today.

LB33