COMMONWEALTH OF PENNSYLVANIA HOUSE OF REPRESENTATIVES

APPROPRIATIONS COMMITTEE HEARING

STATE CAPITOL MAIN BUILDING ROOM 140 HARRISBURG, PENNSYLVANIA

MONDAY, FEBRUARY 24, 2020

PRESENTATION FROM DEPARTMENT OF HEALTH AND DEPARTMENT OF DRUG & ALCOHOL PROGRAMS

BEFORE:

HONORABLE STANLEY SAYLOR, MAJORITY CHAIRMAN HONORABLE MATT BRADFORD, MINORITY CHAIRMAN HONORABLE ROSEMARY BROWN HONORABLE SHERYL DELOZIER HONORABLE GEORGE DUNBAR HONORABLE HONORABLE HONORABLE HONORABLE HONORABLE HONORABLE HONORABLE JOHN LAWRENCE HONORABLE HONORABLE HONORABLE CHRIS QUINN HONORABLE HONORABLE HONORABLE HONORABLE HONORABLE HONORABLE

————————— JEAN DAVIS REPORTING POST OFFICE BOX 125 • HERSHEY, PA 17033 Phone (717)503-6568 1 BEFORE (cont.'d): HONORABLE 2 HONORABLE HONORABLE CAROLYN COMITTA 3 HONORABLE AUSTIN DAVIS HONORABLE 4 HONORABLE MARTY FLYNN HONORABLE EDWARD GAINEY 5 HONORABLE HONORABLE 6 HONORABLE HONORABLE STEPHEN McCARTER 7 HONORABLE BENJAMIN SANCHEZ HONORABLE 8

9 ALSO IN ATTENDANCE:

10 DAVID DONLEY, REPUBLICAN EXECUTIVE DIRECTOR RITCHIE LaFAVER, REPUBLICAN EXECUTIVE DIRECTOR 11 ANN BALOGA, DEMOCRATIC EXECUTIVE DIRECTOR TARA TREES, DEMOCRATIC CHIEF COUNSEL 12 HONORABLE HONORABLE PAM DeLISSIO 13 HONORABLE CRIS DUSH HONORABLE 14 HONORABLE JOE HOHENSTEIN HONORABLE 15 HONORABLE HONORABLE 16 HONORABLE HONORABLE 17 HONORABLE HONORABLE DAVE ZIMMERMAN 18

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21 JEAN M. DAVIS, REPORTER NOTARY PUBLIC 22 23

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2 1 I N D E X TESTIFIERS 2

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4 JENNIFER SMITH, SECRETARY, 5 DEPARTMENT OF DRUG & ALCOHOL 5 DR. RACHEL LEVINE, SECRETARY, 9 6 DEPARTMENT OF HEALTH

7 ELLEN DiDOMENICO, DEPUTY SECRETARY, 17 DEPARTMENT OF DRUG & ALCOHOL 8 SARAH BOATENG, EXECUTIVE DEPUTY SECRETARY, 45 9 DEPARTMENT OF HEALTH

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3 REPRESENTATIVE DUNBAR: Good afternoon.

4 We're going to get started. First off, we are

5 ready to start the hearing for DDAP and the Department of

6 Health.

7 Secretary Smith and Secretary Levine, if you

8 could introduce everybody who is with you.

9 SECRETARY JENNIFER SMITH: Sure. Yes.

10 Good morning. This is my Deputy Secretary, Ellen

11 DiDomenico.

12 DEPUTY SECRETARY ELLEN DiDOMENICO: Good

13 afternoon, everyone.

14 SECRETARY RACHEL LEVINE: This is my Executive

15 Deputy Secretary, Sarah Boateng.

16 REPRESENTATIVE DUNBAR: Okay. Anybody who is

17 going to testify, could you please stand and raise your

18 right hand to be sworn in?

19

20 (Witnesses sworn en masse.)

21 REPRESENTATIVE DUNBAR: Please have a seat.

22 As we have been doing, we have been waiving

23 opening statements and getting right to questions, if that's

24 okay with everybody here.

25 SECRETARY RACHEL LEVINE: Yes.

4 1 SECRETARY JENNIFER SMITH: Perfect.

2 REPRESENTATIVE DUNBAR: And as you can tell,

3 Representative Saylor is a bit under the weather so I'm

4 going to be filling in and Representative Gainey is going to

5 help on the other side of the aisle temporarily as well.

6 So our first questions will come from

7 Representative Hahn.

8 REPRESENTATIVE HAHN: Thank you, Chairman.

9 Good afternoon, Secretaries, Deputy Secretaries.

10 Good to see you.

11 Secretary Smith, I'm starting out with DDAP

12 today.

13 SECRETARY JENNIFER SMITH: Sounds good.

14 REPRESENTATIVE HAHN: All right. The Department

15 contracts with the Single County Authorities to provide

16 prevention, intervention, treatment, and recovery-oriented

17 services. Are they required to contract with evidence-based

18 and evidence-informed programs or do they contract with any

19 provider they want to contract with?

20 SECRETARY JENNIFER SMITH: That's a great

21 question. We do contract with 47 different Single County

22 Authorities. Those 47 Single County Authorities represent

23 all 67 counties across the Commonwealth. So they are

24 responsible for doing a localized needs assessment and then

25 strategic plan. And that is across the full continuum of

5 1 care, so in prevention, intervention, treatment, and

2 recovery support services.

3 So over the last several years, we've been moving

4 in the direction of ensuring that our funding is being used

5 for, if not evidence-based, at least evidence-informed

6 programming. So there used to be a wonderful list out on

7 SAMHSA's website that indicated what kinds of programs fell

8 into those categories.

9 SAMHSA changed their perspective a little bit on

10 what that list looked like and had pulled the list down for

11 a little while. So that caused some confusion amongst folks

12 as to what kinds of programs were able to be supported

13 through our Federal funding. But that website is now

14 functional again. It has been restructured a bit.

15 REPRESENTATIVE HAHN: But they're not required --

16 if a program is not on that list that they're

17 evidence-based, they're not required to contract with them?

18 SECRETARY JENNIFER SMITH: So if those programs

19 are not part of that list, then they would need to seek our

20 approval in order to utilize the funds for that programming.

21 So one of the reasons that we went that route is because

22 there were counties utilizing our funding for programs like

23 scare tactics. And that is not an evidence-based program.

24 And so we have put out some specific guidance around those

25 programs in particular. It doesn't prohibit the Single

6 1 County Authority from utilizing those programs. It

2 prohibits them from utilizing our funding to support those

3 programs.

4 REPRESENTATIVE HAHN: Do the CSAs provide outcome

5 measures to show that the programs are having good outcomes

6 and then to continue or are they required to change if they

7 don't have any evidence-based outcomes?

8 SECRETARY JENNIFER SMITH: Yeah. So they are

9 required to report to us in terms of how many folks they're

10 serving, how many programs they're providing, and the

11 sourcing of all the funding that's being utilized.

12 So we're in the process right now of implementing

13 a new process called a strategic prevention framework, which

14 establishes how they do their needs assessment process, the

15 planning process, the evaluations, and the study of those

16 outcomes.

17 So we've piloted with -- and I don't know the

18 exact number of counties that we've piloted with in terms of

19 implementing that new process. Oh, they're all doing it

20 now. Okay. So all different levels of implementation, but

21 that will be a more stringent requirement in terms of what

22 they're reporting to us without outcomes and justifying the

23 funding that they're using to support the programs.

24 REPRESENTATIVE HAHN: Okay. Is there

25 medication-assisted treatment in all 67 counties?

7 1 SECRETARY JENNIFER SMITH: Yes. Absolutely.

2 REPRESENTATIVE HAHN: Okay. And are they

3 required to provide the same information? Do they do as

4 good a job as any of the other treatments, better, or worse?

5 SECRETARY JENNIFER SMITH: So let me just give a

6 quick clarifying statement. Medication-assisted treatment

7 is not a thing. It's not an entity. It is a type of

8 treatment that can be delivered to individuals who have

9 substance use disorder. So it's really basically just

10 medication that's utilized by some individuals to support

11 their path through treatment and into recovery.

12 REPRESENTATIVE HAHN: But is that -- is there any

13 data as far as like a relapse? So if someone is taking the

14 medicine treatment other than -- is there some type of data

15 that shows that it helps or doesn't help?

16 SECRETARY JENNIFER SMITH: Yeah, there is. I

17 don't have the statistics right at my fingertips.

18 Dr. Levine might. She looked like she was paging

19 through her statistics here.

20 We do have some good information though that has

21 come to us from the Managed Care Organizations who fund our

22 medical assistance clients. We'd be happy to share that

23 data with you. One of the largest entities is CCBH. They

24 cover the bulk of the Commonwealth actually. And they have

25 some pretty interesting statistics in terms of how many

8 1 folks are utilizing medication as part of their treatment

2 regimen and the data does, in fact, show that engagement in

3 treatment is longer for individuals with opioid use disorder

4 who are on some form of medication-assisted treatment.

5 We'd be happy to share that data with you.

6 REPRESENTATIVE HAHN: Okay. Thank you.

7 SECRETARY JENNIFER SMITH: Um-hmm.

8 REPRESENTATIVE HAHN: Secretary, did you have

9 that information?

10 SECRETARY RACHEL LEVINE: Sure. Thank you.

11 I would like to support Secretary Smith's

12 comments about the utility of medication-assisted treatment,

13 sometimes in this case called medication for opioid use

14 disorder, for patients with the disease of addiction to

15 opioids, with opioid use disorder. And so that is really

16 the standard of care as recommended by SAMHSA and Health and

17 Human Services and the Federal Government utilize throughout

18 the states for patients suffering with opioid use disorder.

19 There was a recent article that I wanted to

20 highlight. The article is from JAMA, the Journal of the

21 American Medical Association. It was published on February

22 5th, 2020, so it's hot off the press.

23 And this article is called, Comparative

24 Effectiveness of Different Treatment Pathways for Opioid Use

25 Disorder.

9 1 And so this was a retrospective analysis using

2 this large data warehouse where they looked at actually over

3 40,000 individuals with opioid use disorder. And their

4 conclusion was -- and I'm quoting the abstract of the

5 article -- only treatment with Buprenorphine or Methadone

6 was associated with a reduced risk of overdose during a

7 three-month and twelve-month followup. Treatment with

8 Buprenorphine -- that's the brand name; one brand name of

9 that is Suboxone, but there are other brand names -- or

10 Methadone was associated with a reduction in serious

11 opioid-related acute care during that three- and

12 twelve-month followup.

13 So there are many articles in the reference

14 section of this article. But this is the most recent as of

15 approximately two or three weeks ago, which outlines that

16 for patients with opioid use disorder, the standard of care

17 is to have medication-assisted treatment. That can include

18 Methadone, that can include Buprenorphine medications, and

19 can include long-acting Naltrexone, which is called

20 Vivitrol, although in this article long-acting Naltrexone

21 was not as effective as Buprenorphine and Methadone.

22 Now the standard is to include other aspects of

23 treatment if possible with the medication. The medication

24 assists the treatment. So that would include various types

25 of counseling. That would include Case Management services,

10 1 etc. That would be the gold standard. But it highlights

2 the importance of the use of medication-assisted treatment,

3 or MOUD, given the current opioid crisis that we're facing.

4 We have worked to expand that, as the Secretary

5 was referring to, throughout Pennsylvania with 45 Centers of

6 Excellence for patients with Medicaid, with satellites.

7 There are now 70 sites for the Centers of Excellence as well

8 as 9 programs called PacMAT, or Pennsylvania Coordinated

9 Medication Assisted Treatment, P-a-c-M-A-T.

10 Those now include Temple, the Wright Center in

11 Scranton, Lehigh Valley Health System, Penn State Health

12 System, UPMC Pinnacle, Wellspan, UPMC in Pittsburgh and

13 Allegheny. So you can see some of our finest academic

14 institutions that live a hub and spokes model to expand

15 evidence-based quality MAT throughout the State.

16 REPRESENTATIVE DUNBAR: Thank you,

17 Representative.

18 Thank you, Secretary.

19 Next will be Representative McCarter.

20 REPRESENTATIVE McCARTER: Thank you very much,

21 Mr. Chairman.

22 Again, thank you very much for being here today.

23 And I thought I would try to give you an opportunity today

24 because I know there's a health issue that obviously many

25 Pennsylvanians and people throughout the country are very

11 1 concerned with at the present moment, that being the

2 COVID-19 epidemic potentially.

3 First of all, let me thank you very much for the

4 press briefing last week for Legislators and for their

5 offices and updating us on the situation last week. But as

6 you said, I think in that press conference or that briefing

7 last week, the situation is evolving and changing very

8 quickly and we all need to be aware of that.

9 So I thought it would be a good opportunity today

10 for you to update us a little bit more as to how you see the

11 situation as it's evolving now to where over 30 countries

12 have been impacted and the likelihood is that we will see

13 that in a greater form here in the United States as well and

14 possibly in Pennsylvania.

15 So would you comment a little bit on that

16 situation and the likelihood of it reaching Pennsylvania in

17 the near future and how people should be preparing for that?

18 SECRETARY RACHEL LEVINE: Thank you very much for

19 the opportunity. I really welcome the opportunity to talk

20 about this novel Coronavirus.

21 To repeat a couple of things that I said during

22 the briefing that we had, Coronavirus, its name comes from

23 how it looks under an electron microscope. There are many

24 different types of Coronaviruses. Many upper respiratory

25 infections and colds we get are from a Coronavirus. But

12 1 there are some Coronaviruses that seem to start to infect

2 people starting with animals. And that's how this seems to

3 have started.

4 Two previous Coronaviruses that started in a

5 similar way that affected the world were SARS in the early

6 2000s and MERS earlier this decade, which were significant

7 but not as significant as it appears as this outbreak.

8 The infection is now called COVID-19 by the World

9 Health Association Organization and by the CDC and Health

10 and Human Services.

11 It seems to have infected people coming from an

12 animal in China, in Wuhan, China, from what are called wet

13 markets, where they have many different types of wild

14 animals that are actually then sold. They are living at

15 that time. They're sold. They're butchered for food. And

16 that could include bats. It can include animals called

17 Crivitz, Pangolins, swine, many different types of animals.

18 Unfortunately that type of market is a breeding

19 ground of viruses that can then go and infect people. And

20 it's still not clear -- probably a bat, but it's still not

21 clear what led to this Coronavirus and how it started.

22 This has obviously caused significant issues in

23 Wuhan, China, and Hubei Provence in China. But as you

24 mentioned, it is now reaching many different countries and

25 actually many different continents.

13 1 As of this morning worldwide, there were 79,524

2 cases worldwide. There have been 2,626 deaths. That

3 includes infections primarily in China but also 833

4 infections in South Korea, 215 now in Italy, so another

5 continent, 61 Iran, 154 in Japan. So it has become a

6 worldwide phenomenon now in many different countries and

7 poses a significant health threat to the United States as

8 well as globally.

9 In the United States there are now 53 cases.

10 That includes actually 36 cases from the Diamond Princess

11 Cruise Ship. And so we actually even doubled -- it went up

12 today from this morning to now.

13 In Pennsylvania, we have had no cases of

14 COVID-19. We have tested a number of individuals according

15 to the CDC guidelines and all of those tests were negative.

16 We have tracked individuals that have come from China

17 working very closely with our county and municipal Health

18 Department partners.

19 We have been in constant contact with our county

20 and municipal Health Department Agencies, as well as with

21 other states and the CDC as we continue to track this global

22 phenomenon. But some of the new information, even from last

23 week, is the spread to South Korea, the spread to Italy, to

24 Iran, Japan, and the level that it is spreading.

25 There are two parameters of viruses, especially

14 1 novel viruses, that you have to look at. One is, how

2 infectious is it? How many people who are exposed to a

3 person who is contagious will get it? And then the other is

4 how serious it is, how many people will die from that. So

5 you can plot that on a graph.

6 The worst-case scenario of any virus would be

7 Smallpox. Smallpox is -- which has been eradicated from the

8 world. Smallpox is tremendously infectious and tremendously

9 lethal. That would be the absolute worst-case scenario.

10 Where we are now is a virus that is more

11 contagious than the flu, but not nearly as much as Smallpox

12 or Measles. And it has approximately a 20 times death rate

13 than the flu. So it has a death rate of approximately 2 to

14 2.5 percent of people who get it will die of various

15 complications. The flu is approximately 0.1.

16 So you can see that this poses a significant risk

17 globally as well as the United States. So we are in

18 incident command mode with the Department of Health. And so

19 we have incident commanders that report to me as the

20 Secretary of Health. And of course, I report to the

21 Governor. And I updated the Governor this morning on

22 COVID-19. And then there are also, of course, Federal

23 agencies that we are working with very closely. And so that

24 includes the CDC and Health and Human Services. And so that

25 is kind of the hierarchy. So we are watching this extremely

15 1 closely for possible transmission by the community in the

2 United States and in Pennsylvania. And we are watching it,

3 you know, every moment of every day.

4 REPRESENTATIVE McCARTER: Thank you very much for

5 your update. I appreciate that.

6 Thank you, Mr. Chairman.

7 REPRESENTATIVE DUNBAR: Thank you,

8 Representative.

9 And I wanted to note that we have been joined by

10 members that are not on the Appropriations Committee,

11 Representative Zimmerman, Representative Daley,

12 Representative DeLissio, Representative Innamorato.

13 Next question will come from Representative

14 Rothman.

15 REPRESENTATIVE ROTHMAN: Thank you.

16 Over here. Secretary, thank you for being here.

17 In the past two years -- and I think the number

18 is going to be 85 million this year in Federal opiate grants

19 -- you have proposed 1.5 million for Drug Court operations.

20 Cumberland County, where I represent, has an outstanding

21 Opiate Court that has had great results.

22 I'm curious to know how we're going to fund

23 these, can we help get Cumberland County funding, and how

24 many other counties have or are considering Drug Courts and

25 what do we do to create more of them.

16 1 SECRETARY RACHEL LEVINE: Thank you for that

2 question. May I defer to my colleagues at DDAP? because the

3 grant flows through DDAP.

4 REPRESENTATIVE ROTHMAN: Sure.

5 DEPUTY SECRETARY ELLEN DiDOMENICO: Thank you.

6 Yes, we are working very closely with a number of

7 counties around Drug Courts. And I want to distinguish

8 between two things. So we have funded in almost every

9 county that has a Drug Court the ability for those counties

10 to use the treatment dollars that we make available to them

11 for individuals being served within the Drug Courts. The

12 dollars that you're referencing specifically were for the

13 operations of Drug Courts.

14 So we are now working with a number of counties.

15 And actually we are working with a program in Cumberland

16 County to help fund the actual Drug Court operations. What

17 we mean by that is the work that happens at the Case

18 Management kind of level, so the ability for someone to be

19 able to track those individuals who are being served within

20 the Drug Courts and to make sure that they connect to all

21 the resources that they need.

22 So all of our Single County Authorities have the

23 ability to use dollars to treat individuals who would be

24 present in all parts of the Criminal Justice System,

25 including those that are involved in local Drug Courts.

17 1 We also work with Pennsylvania Commission on

2 Crime and Delinquency to do some of the application work to

3 be able to fund those courts specifically and continue to

4 work with them to be able to make sure that those dollars

5 are used most effectively across the Commonwealth.

6 REPRESENTATIVE ROTHMAN: Thank you.

7 SECRETARY JENNIFER SMITH: I would just add that,

8 you know, we really appreciate -- is this Judge Brewbaker's

9 opiate court? Yes. We really appreciate her work and all

10 that she has done there. And as long as the dollars

11 continue to flow to us from the Federal Government, we're

12 hoping that we can continue to sustain funding to those

13 kinds of organizations and hopefully even expand them

14 further across the Commonwealth.

15 REPRESENTATIVE ROTHMAN: Yes, we're very proud of

16 what they are doing there.

17 SECRETARY JENNIFER SMITH: You should be.

18 REPRESENTATIVE ROTHMAN: It's been very

19 effective.

20 Thank you.

21 REPRESENTATIVE DUNBAR: Thank you,

22 Representative.

23 Next will be Representative Bullock.

24 REPRESENTATIVE BULLOCK: Thank you, Mr. Chairman.

25 Good afternoon. I'm actually going to skip over

18 1 my usual question because as I review your departments, both

2 of your departments fare pretty well when hiring and

3 recruiting women as well as communities of color and other

4 minority groups, so I want to thank you for your efforts

5 there.

6 My two sets of questions do focus on keeping

7 Pennsylvanians safe, the first being Governor Wolf's

8 initiative around gun violence and your Department's

9 response to that, Secretary -- Dr. Levine. The division of

10 violence prevention within a Department of Health is not

11 funded, nor does it state that it has any additional

12 staffing.

13 But could you share with me how that particular

14 division will be working with the Governor and helping to

15 keep Pennsylvanians safe and particularly looking at gun

16 violence as a public health issue? And I know you are very

17 much committed to that.

18 The second round of questions is also for Dr.

19 Levine on another issue that I think you've been very

20 committed to, which is maternal mortality. And as we look

21 at Pennsylvania we have unfortunately a high maternal

22 mortality rate with 11.1 deaths per 100,000 live births.

23 And when you look at communities of color, particularly

24 black women, that rate rises to 24.7 deaths per 100,000. We

25 have established through Act 24 of 2018 the Maternal

19 1 Mortality Review Committee. Can you please just talk about

2 the progress of the committee and the work that it's doing

3 to reduce these numbers?

4 SECRETARY RACHEL LEVINE: Thank you for those

5 questions.

6 First in terms of gun violence, it's absolutely

7 clear that we have to look at gun violence to ensure the

8 health and safety of people in Pennsylvania as a public

9 health issue and look at it through that public health lens.

10 It is one of the leading causes of premature death in the

11 United States. And even in Pennsylvania in 2017, there were

12 1,636 deaths due to firearms according to the CDC.

13 So as you know, the Governor signed an Executive

14 Order on reducing gun violence, assigning tasks to many

15 different departments as well as the Commission on Gun

16 Violence Prevention through the Pennsylvania Commission of

17 Crime and Delinquency.

18 So one thing we do is that we participate

19 robustly in the Special Council on Gun Violence. I have a

20 seat on that Commission and Council and I will be there

21 tomorrow actually for one of the meetings. We participate

22 fully using our experience in public health to inform that

23 Council.

24 We have established a Division of Violence

25 Prevention and particularly focusing on gun violence within

20 1 the Department of Health in our Bureau of Health Promotion

2 and Risk Reduction. So there is not specific funding in

3 this budget, although we'll continue to work with the

4 Governor's Budget Office on that. But we are working to

5 fill those positions actually from some complement that we

6 already have.

7 So we will be filling those positions. We'll be

8 starting to recruit quite soon to stand that division up as

9 soon as possible. We are establishing a Gun Violence Data

10 Dashboard to better understand the scope, frequency,

11 geography, and populations that might be affected by

12 violence and particularly of gun violence. We are hoping

13 later in the spring to have the first iteration of that Gun

14 Violence Data Dashboard.

15 In addition, we were asked to develop a

16 Multidisciplinary Suicide Death Review Team, similar to the

17 Maternal Mortality Team that you have described. We would

18 look forward to working with you in the Legislature on

19 legislation to support that. As you know, we have a

20 decentralized coroner system with many different coroners in

21 all the counties to be able to get that data and work with

22 the coroners. It would be very helpful for us to have

23 legislation authorizing that so that we can in a timely way

24 and efficiently get the data we need for the suicide death

25 review from our coroners.

21 1 In terms of your second question, as you stated,

2 Act 24 of 2018 established the Maternal Mortality Review

3 Committee, and as you appropriately pointed out, maternal

4 deaths have been rising in the United States, including in

5 Pennsylvania, where the only developed country where

6 maternal deaths, maternal mortality, has been rising. And

7 as you also pointed out, there is such a significant

8 disparity.

9 In Pennsylvania it has been pretty much level for

10 Caucasian women. And it has been going up significantly for

11 women of color, particularly African-American women. So

12 it's a health equity issue for us.

13 The Maternal Mortality Review Committee will

14 review all pregnancy-associated deaths in the Commonwealth,

15 not including Philadelphia, which has its own committee,

16 regardless of cause of death, so it includes drug-related

17 deaths, homicides, suicide, but also other medically related

18 deaths or specifically pregnancy-related deaths.

19 That Committee has been established. We had our

20 first meeting in February of 2019. The Committee

21 established its mission and vision in July. It began

22 reviewing pregnancy-associated cases. And I want to point

23 out in September of 2019, we received a $2.25 million grant

24 from the CDC over five years through the CDC enhancing

25 reviews and surveillance to eliminate the maternal mortality

22 1 program. So we are working to hire staff now to further

2 expand the Maternal Mortality Review Committee. We have

3 members from throughout the Commonwealth, experts in this

4 field, according to the dictates of the legislation. And

5 the next meeting is in March.

6 We also have established -- we launched in

7 coordination with the Jewish Health Care Foundation what's

8 called a PQC, or Perinatal Quality Collaborative. It

9 includes membership from DDAP, the Department of Health,

10 Department of Human Services, and many other constituents

11 and it's going to look at maternal mortality, opiate use

12 disorder among pregnant women, and babies born with Neonatal

13 Abstinence Syndrome.

14 REPRESENTATIVE BULLOCK: Thank you, Secretary

15 Levine. And thank you for all of your work on this.

16 SECRETARY RACHEL LEVINE: Thank you.

17 REPRESENTATIVE DUNBAR: Thank you,

18 Representative.

19 And, Secretary, we do appreciate the information

20 but we have a lot of questions.

21 SECRETARY RACHEL LEVINE: Okay.

22 REPRESENTATIVE DUNBAR: If once the red light

23 goes on, if we can find a stopping point, it would be

24 greatly appreciated. I didn't want to interrupt you during

25 the Coronavirus. I would have felt bad about that. But if

23 1 we could find a stopping point, it's always appreciated.

2 I also wanted to mention we have been joined by

3 Representative Hohenstein. And next for questions will be

4 Representative Brown.

5 REPRESENTATIVE BROWN: Thank you, Mr. Chairman.

6 And thank you, Madame Secretary and all of you,

7 for being here this afternoon.

8 As we continue on the conversation of health

9 crises, unfortunately we had the Coronavirus discussion a

10 little bit. And I know, Secretary, that you will understand

11 I'm going to talk to you again about Lyme Disease and

12 tick-borne illness. Yourself and your staff have had many

13 meetings with me in regards to this issue and my concerns.

14 And it definitely is still a very serious and growing

15 concern in Pennsylvania.

16 Some of the most recent numbers I've seen have

17 shown there's been a 300 percent increase in Lyme Disease in

18 the northeastern states. So it is something that I believe

19 we really have made some progress on together. And we are

20 moving forward.

21 But the East Stroudsburg University tick lab,

22 which we established the free tick testing program two years

23 ago and actually put in a line item last year, has had some

24 great results and I just wanted to point this out just for

25 the record and for the members that since April of 2019 to

24 1 February 24th of this year, there's been 12,333 ticks that

2 have been tested. Of those ticks tested, 51.5 percent of

3 them tested positive for either Lyme Disease or

4 anaplasmosis. So that's over half obviously. And so

5 there's a great concern.

6 But it's providing some wonderful information for

7 us as far as for the patient/doctor relationship as a tool.

8 And it's also giving us some pathogen information and

9 science information that we need. What's concerning to me

10 is, as I see that need and I see the proposed budget by the

11 Governor, having the 3 million moved down to 2.5 million,

12 your thoughts on that?

13 SECRETARY RACHEL LEVINE: Sure. So you are

14 correct. Lyme Disease continues to be a very significant

15 public health problem here in Pennsylvania. And we have

16 been very pleased to collaborate with your office and to

17 collaborate with East Stroudsburg.

18 I believe that the 2.5 is exactly the same as the

19 Governor put into the budget last year. And I believe that

20 through legislative additions and your office, the extra

21 $500,000 was add ed.

22 I think it was added to DHS's budget the first

23 year and last year to our budget. The budget is just a

24 starting point. We'd be pleased to collaborate with your

25 office. And if you and the Legislature add that $500,000

25 1 for continuing to work with East Stroudsburg University, we

2 will renew that contract and we are very pleased to continue

3 to work with them because they're doing great work.

4 REPRESENTATIVE BROWN: They are doing great work,

5 which is why I'm surprised why this would be pulled out, so

6 to speak. Can you give me some more details why it was

7 pulled out?

8 SECRETARY RACHEL LEVINE: I don't think there was

9 any specific reason why it was pulled out. I think that

10 last year it was a legislative add so the expectation might

11 be that this year it's a legislative add. But there was no

12 specific policy reason why that contract was not included.

13 REPRESENTATIVE BROWN: Right. So are we

14 continuing to have conversations with East Stroudsburg

15 University, with the Department of Health, with DEP, in a

16 combined effort?

17 SECRETARY RACHEL LEVINE: Yes.

18 REPRESENTATIVE BROWN: Okay.

19 SECRETARY RACHEL LEVINE: And they have received

20 or are receiving that money through our process. All that

21 contract was worked out. We'd be pleased to do that again.

22 I don't think -- there was not a -- there was no specific

23 again policy initiative why that specific money wasn't

24 included. I think that the expectation might be that it

25 will be the same as last year as a legislative addition.

26 1 REPRESENTATIVE BROWN: Okay. So there would be

2 no conversations that the 500,000 could come out of the 2.5

3 million that's currently allocated?

4 SECRETARY RACHEL LEVINE: That would limit our

5 ability to use that money for our continued activities. So

6 right now that money is going towards surveillance. It's

7 going towards prevention and education. So accounting would

8 be 942,000 to education and outreach, 118,000 for testing

9 capabilities, 423,000 for planning and prevention, the 500

10 to East Stroudsburg, as you mentioned, 912,000 for

11 surveillance. That includes work with DEP in terms of their

12 tick surveillance, in terms of numbers of ticks in different

13 counties, and $105,000 for administration. So that's the 3

14 million.

15 REPRESENTATIVE BROWN: Okay.

16 SECRETARY RACHEL LEVINE: If you take 500 out of

17 the 2.5, then some of that activity will be less.

18 REPRESENTATIVE BROWN: Do you know for the tick

19 testing that the DEP or their surveillance that they are

20 doing, is there any replication or anything there that we

21 might not need to do the DEP surveillance in that manner and

22 we could utilize the testing that East Stroudsburg

23 University is doing on the surveillance?

24 SECRETARY RACHEL LEVINE: I'd have to go back to

25 my staff and talk about some of the details of the DEP

27 1 surveillance. I've seen them do their tick. I mean, they

2 are often looking for the numbers of ticks in different

3 counties, which is not something that East Stroudsburg would

4 be doing.

5 REPRESENTATIVE BROWN: Right.

6 SECRETARY RACHEL LEVINE: So they're not -- my

7 understanding is they're not so much testing the tick as

8 they are doing surveillance of the tick population.

9 REPRESENTATIVE BROWN: Okay.

10 SECRETARY RACHEL LEVINE: But I'd have to get

11 details from my staff and get back to your office.

12 REPRESENTATIVE BROWN: Okay. Thank you, Madam

13 Secretary.

14 SECRETARY RACHEL LEVINE: Thank you.

15 REPRESENTATIVE BROWN: Thank you, Mr. Chairman.

16 REPRESENTATIVE DUNBAR: Thank you.

17 Next will be Representative Fiedler.

18 REPRESENTATIVE FIEDLER: Hi. Thank you for being

19 here this afternoon. I want to switch gears a little bit

20 and ask you about a different health issue.

21 A few months ago, a Philadelphia teacher made

22 national news when she announced that she had been diagnosed

23 with Mesothelioma. And many people wondered if her

24 diagnosis was a result of conditions in schools that she had

25 taught in for 28 years. I think it's fair to say we all

28 1 want our children and our educators to spend their days in

2 safe and healthy buildings.

3 And I have to say, as the daughter of two public

4 school teachers, the fact that any teacher wonders if a

5 diagnosis like that is the result of their lifelong

6 commitment to educating the next generation, I know for many

7 of us it's heartbreaking.

8 Asbestos fibers when disturbed and inhaled can

9 cause serious lung diseases and cancer, as we know. And

10 there is asbestosis in possibly hundreds of schools across

11 the Commonwealth that can and in some cases already has had

12 a health impact on the lives of students and educators and

13 staff across our state.

14 Can you talk to us about what is being done to

15 make sure that our schools are not poisoning our students

16 and our teachers?

17 And I do want to note that, obviously, the

18 Governor recently proposed using $1 billion to remediate

19 asbestosis and lead in our schools. And that's something

20 that I absolutely support and I think that is a number that

21 is in line with the size of this crisis and the public

22 health emergency. But if you could talk with us about that,

23 please.

24 SECRETARY RACHEL LEVINE: Sure. Thank you for

25 that question.

29 1 So as you pointed out, asbestosis is an extremely

2 toxic fiber. It can cause mesothelioma, a specific cancer

3 of the lining of the lung. It can also cause mesothelioma

4 in other types of tissues. And also it can cause

5 asbestosis, which is a serious lung disease.

6 And it really is a significant environmental

7 issue in schools in Philadelphia and in many parts of

8 Pennsylvania. So the Department of Health, we were pleased

9 to stand with the Governor as he announced action and

10 proposed action against, quote, unquote, as he said, toxic

11 schools to protect our children. We would be very pleased

12 to partner with the Governor's Office and the department of

13 DEP as well as the Department of Education in terms of

14 making schools safer.

15 And you mentioned the funding mechanism that the

16 Governor was proposing. So we would be very pleased to

17 partner in all of that. It's not a specific. I don't have

18 a specific division or bureau that would be looking at that

19 but we are pleased to help in any way we can.

20 REPRESENTATIVE FIEDLER: Thank you for that.

21 And could you talk with us specifically about

22 what's being done on the health challenges related to lead

23 poisoning, which we know is an issue both in schools but

24 also at homes, at daycare facilities? Could you talk about

25 the work that's being done to make sure that people in

30 1 Pennsylvania are safe from lead poisoning, please?

2 SECRETARY RACHEL LEVINE: Absolutely.

3 So as you pointed out, there is a lot of concern

4 about the effect of lead poisoning on children in

5 Pennsylvania. There is no safe level of lead. It's a toxic

6 substance no matter what the level is. And we are concerned

7 about the number of proportions of Pennsylvania children who

8 have been exposed to lead, although that number has been --

9 the lead levels have been going down over the last number of

10 years.

11 Homes built before 1978 are likely to contain

12 lead-based paint. And if that is aerosolized or eaten then

13 it can cause lead poisoning. We currently receive Federal

14 funding from HUD to implement the Lead Hazard Control

15 Program where we are looking at trying to remediate 186

16 homes and make the lead safe.

17 In addition, we receive funding from the CDC for

18 the Childhood Lead Poisoning Prevention Program. In

19 addition, our community health nurses will follow up with

20 any child that has a lead level greater than or equal to 5,

21 which is the lower level, at least right now, set by the CDC

22 to talk about sources, potential sources of lead

23 contamination with those children.

24 We did publish the 2018 Childhood Lead

25 Surveillance Report in January, so a month ago. And we had

31 1 some extra data linkage. We have actually an epidemiology

2 research associate to perform this extra data analysis. And

3 so that will continue when we do the 2019.

4 And the Governor has talked about working through

5 various mechanisms to remediate lead, both in the schools

6 through the same program that you talked about, but also

7 we'd love to remediate more homes. And that would be part

8 of his initiative for using potentially the Shale Tax to

9 fund, to restore Pennsylvania and that initiative, and using

10 that money from a Shale Tax to help remediate more houses in

11 Pennsylvania.

12 One legislation that we have asked for and we'd

13 love the Legislature to consider is universal lead testing

14 of children. Right now the only children really that get

15 tested for lead have Medicaid or CHIP. And if we can have

16 universal testing, it would help us understand the true

17 burden of lead poisoning in Pennsylvania.

18 REPRESENTATIVE FIEDLER: Thank you very much.

19 REPRESENTATIVE DUNBAR: Thank you.

20 Next will be Representative Struzzi.

21 REPRESENTATIVE STRUZZI: Thank you, Mr. Chairman.

22 Good afternoon .

23 SECRETARY RACHEL LEVINE: Good afternoon.

24 REPRESENTATIVE STRUZZI: I have questions for

25 both of you, but we'll start with Secretary Smith first. My

32 1 question relates to recovery, houses which I think are key

2 in the recovery process. You hear a lot of stories about

3 people suffering through addiction being mistreated in

4 recovery houses. And so Act 59 of 2017 required your agency

5 to regulate recovery houses.

6 SECRETARY JENNIFER SMITH: Yes.

7 REPRESENTATIVE STRUZZI: So my question is -- and

8 maybe there's some misinformation out there. But your

9 website right now says that you're working to get the

10 program up and running. And you do have an augmentation of

11 450,000 in this year's budget and then 900,000 in next

12 year's budget.

13 So with that said, where are we in regulating

14 recovery houses?

15 SECRETARY JENNIFER SMITH: Yes, that's a great

16 question. And I'll try to be really brief with my answer to

17 give you time to ask Dr. Levine her questions.

18 So in terms of where we stand with licensing

19 recovery houses, the way the legislation passed did not

20 require our department to put those draft regulations out

21 for public comment. But because we understand what a

22 critically important task this is, we opted to put those

23 draft regulations out for public comment because we really

24 want to ensure that the houses that we will be looking to

25 license had some input in terms of what that regulatory

33 1 process was going to look like.

2 What we didn't want to do was enable no houses to

3 become certified because that is a really critical service

4 that we have to offer. So those went out for public

5 comment. We got very differing opinions in exchange, you

6 know, in return. Some said these aren't nearly strict

7 enough. Some said these take things way too far.

8 And so we had to take some time to really balance

9 out what that was going to look like. So we anticipate this

10 week those regulations will be leaving my office to begin

11 that final review process before heading to ERC. So we are

12 hopeful that those regulations will be in place by the end

13 of the fiscal year.

14 In terms of where we are with the process,

15 however, we have already organizationally created positions

16 that will be used to license these homes. We will be

17 posting and hiring for those positions within the next

18 month. We're also working on developing the online

19 application tool that will be used to both submit

20 applications as well as to receive payment.

21 And that's where those augmentations come into

22 play, where we expect to begin receiving, quote, unquote,

23 revenues in terms of the licensing fees that are required

24 for those homes.

25 So we are still working our way through the

34 1 process, but certainly within the next couple of months

2 you'll start to see those regulations working their way

3 through the review process. And we will begin having staff

4 trained so that as soon as the regulations are finalized

5 we're ready to go.

6 We've also developed a LISTSERV that you can join

7 via our website for any houses that are looking to become

8 licensed so that they can stay up to date. And we will be

9 communicating much more frequently with those entities as

10 the time gets closer so that they know what they need to be

11 submitting, who they need to be submitting it to, and so

12 that we're offering technical assistance to them through

13 that process.

14 REPRESENTATIVE STRUZZI: All right. Great. I

15 appreciate that information.

16 My other question relates to medical marijuana

17 and alternative treatments for opiate use and addiction, I

18 guess. We've had medical marijuana in place for some time

19 now. I believe we expanded it to treat 23 different

20 afflictions. Your thoughts on that. Are we doing enough

21 with that? Is there a readily accessible facility to help

22 people with this?

23 And I also have a question -- I know we've had

24 this conversation -- there's other alternative treatments

25 out there, CBD, now hemp in some cases, and kratom, if I'm

35 1 pronouncing it correctly. But your thoughts on these

2 alternative treatments. Are they effective and are we doing

3 enough to help people with that?

4 SECRETARY RACHEL LEVINE: Sure.

5 So in terms of medical marijuana, I think that we

6 have really one of the best medical marijuana programs in

7 the country. It is very medically based. It's for 23

8 serious medical conditions. We had very tight oversight

9 over the grower processes and dispensaries as well as the

10 laboratories.

11 And we have a new program, the Chapter 20

12 Program, which is up and running. We just announced four

13 new sets of clinical registrants to be working with academic

14 research centers. And we definitely need more research.

15 Research has been limited because of how it's scheduled. We

16 need more research to be able to see the total effect of

17 medical marijuana.

18 For CBD, I have concerns about the CBD from hemp

19 because it's an unregulated industry. So I mean, there's

20 CBD from medical marijuana. There's CBD from hemp. The

21 problem is that that's a result of the Federal Farm Bill and

22 it's completely unregulated so I have concerns.

23 And I believe there's a hearing coming up about

24 that. We do not -- are not in favor of kratom. There are

25 some significant concerns about toxicities, particularly

36 1 liver toxicity is associated with kratom, and we do not

2 approve of that use.

3 REPRESENTATIVE STRUZZI: Thank you for the good

4 short answers.

5 REPRESENTATIVE DUNBAR: Thank you,

6 Representative.

7 Next will be Representative Krueger.

8 REPRESENTATIVE KRUEGER: Thank you, Mr. Chairman.

9 Thank you so much for joining us here today.

10 I've got a follow-up question for Secretary Smith about

11 recovery houses based on the question from my colleague.

12 I've talked to a number of providers in Delaware

13 County where we're facing a crisis just like so many places

14 across the Commonwealth. And I'm curious, once these new

15 regulations are enacted, are there any new funding streams

16 that will be available for licensed recovery houses once the

17 license exists?

18 SECRETARY JENNIFER SMITH: Yeah, that's a great

19 question.

20 So if you take a look at the legislation that

21 many of you, thank you, all helped to pass, the requirement

22 for the recovery houses that have to be licensed are those

23 who are going to receive referrals from state entities or

24 want to receive State or Federal dollars.

25 So there are currently some recovery houses -- I

37 1 believe that number is somewhere between 40 and 60 current

2 recovery houses that receive some form of Federal or State

3 dollars through our Single County Authorities. If those

4 entities want to continue to receive those funds, they will

5 need to become licensed recovery houses.

6 So it isn't so much that there's necessarily a

7 new funding stream available for these entities. It's that

8 if they want to continue to receive those funds, they would

9 be required to be licensed entities.

10 REPRESENTATIVE KRUEGER: So presumably to receive

11 the same funding that they are receiving now?

12 SECRETARY JENNIFER SMITH: That's correct.

13 REPRESENTATIVE KRUEGER: But there's not

14 necessarily a new appropriation tied to the regulations

15 being enacted?

16 SECRETARY JENNIFER SMITH: That's correct.

17 REPRESENTATIVE KRUEGER: Okay.

18 And another question. We've talked a lot in this

19 Chamber about Medicaid and the impact of Medicaid expansion.

20 I know in my district there's folks who have been able to

21 get access to treatment by being involved in Medicaid.

22 Can you give us some updated statistics on how

23 many folks are accessing Medicaid in order to get substance

24 use treatment?

25 SECRETARY JENNIFER SMITH: Sure. I'd be happy to

38 1 share with you what I have. And I'm sure that Secretary

2 Miller from the Department of Human Services will be happy

3 to share additional details as well if you have further

4 questions.

5 So in 2018, which is the latest data that I have

6 here, individuals on Medical Assistance with an opiate use

7 disorder diagnosis stood at 124,000 individuals.

8 Individuals who are on Medical Assistance and receiving

9 medication-assisted treatment in 2018 was not quite 150,000

10 individuals. Individuals receiving Naloxone prescriptions,

11 which is that lifesaving overdose reversal drug, was 17,000.

12 And in terms of the numbers of pregnant women who are on

13 Medicaid diagnosed with an opiate use disorder and receiving

14 the evidence-based medication-assisted treatment in the last

15 quarter of 2017 was at 60 percent.

16 And all of those numbers that I mentioned have

17 been climbing since 2015. I will say that in general the

18 admission to treatment of the individuals that our dollars

19 fund -- so this is not Medicaid dollars. These are dollars

20 that go towards uninsured individuals. Those admissions to

21 treatment have actually been dropping.

22 And the reason that those numbers are dropping is

23 because the admissions that the Medicaid program is

24 reporting are increasing. So in fact total numbers of

25 admissions are on the rise but we're seeing a larger

39 1 proportion of those admissions through the Medical

2 Assistance Program.

3 REPRESENTATIVE KRUEGER: And can either of you

4 tell me what's the current number of individuals on Medical

5 Assistance in Pennsylvania right now?

6 SECRETARY JENNIFER SMITH: I don't know the

7 answer. 2.8, Ellen says.

8 REPRESENTATIVE KRUEGER: Okay. So a significant

9 percentage of the population is receiving treatment.

10 And then one last question for Dr. Levine. I saw

11 funding outlined in your budget for a study on public health

12 impacts of fracking.

13 SECRETARY RACHEL LEVINE: Um-hmm.

14 REPRESENTATIVE KRUEGER: Can you tell us about

15 this study? When will it start? Who is responsible? How

16 will we find out the results and, you know, how -- this is

17 something that a number of us in the Legislature have talked

18 about for a long time. There's certainly lots of

19 speculation on public health impacts especially on women who

20 are pregnant and children. What's the Department going to

21 be doing on this and when?

22 SECRETARY RACHEL LEVINE: Thank you.

23 So since 2015, we have been looking at health

24 effects of fracking. So what we did at the beginning was

25 establish an enhanced complaint registry where anybody

40 1 having potential health effects would call us and we would

2 have a robust analysis and database. And then we had some

3 collaboration actually with Colorado, which also has a

4 significant fracking industry.

5 But unfortunately we did not get as many calls as

6 we were hoping for. We did try many different ways to get

7 more people who might be having concerns call us. There had

8 been some concerns about when they'd call the Department of

9 Health in prior years before 2015 that maybe the response

10 was not as robust as it could be.

11 But so we got some information but not nearly as

12 much to do data analysis. So we worked this year and it was

13 approved in the fall to do two separate studies on potential

14 health effects of fracking.

15 One is a study on acute effects. And so that

16 would be acute effects such as asthma, also birth outcomes,

17 etc., and this is going to be in the southwest. And the

18 second, really the first in the country to do a study, a

19 retrospective study, is looking at childhood cancers. So

20 that includes a cancer called Ewing sarcoma, but it's not

21 only Ewing sarcoma, among different counties in the

22 southwest.

23 We have finished our internal scope of work for

24 that study. We have $1.3 million in this year's budget for

25 that study. I believe it's $1.3 million a year. It will be

41 1 for three years to do it, so a total of $3.9 million. And

2 we are in discussions with an academic partner in the

3 southwest -- but the contract is not signed yet so I can't

4 name it -- that we'll work with on that study. And then

5 we're hoping to finish that study by end of term.

6 And this would be really one of the most robust

7 studies done by any State Government on acute effects and

8 then specifically childhood cancers.

9 REPRESENTATIVE KRUEGER: Thank you for your

10 leadership on these issues.

11 SECRETARY RACHEL LEVINE: Thank you.

12 REPRESENTATIVE DUNBAR: Thank you,

13 Representative.

14 And a quick followup. I had a constituent ask me

15 about the same situation. I am from the southwest. And

16 they were wondering if the Environmental Health Project was

17 going to be involved in this.

18 SECRETARY RACHEL LEVINE: No. We are not working

19 with other external stakeholders. We'll be working with an

20 academic partner, a major academic partner in the southwest,

21 in terms of that study.

22 REPRESENTATIVE DUNBAR: That's good.

23 SECRETARY RACHEL LEVINE: But nothing that's been

24 signed or sealed yet, so I can't name the specific partner.

25 And so we'll be outlining a scope of work and then working

42 1 with their experts on the study. This is going to be a

2 retrospective study looking at medical records, as well as

3 other types of records, and trying to correlate it again

4 with acute -- some examples are asthma and birth outcomes,

5 but there will be others and then this unique study looking

6 at childhood cancers.

7 REPRESENTATIVE DUNBAR: Great. Thank you so

8 much.

9 SECRETARY RACHEL LEVINE: Sure.

10 REPRESENTATIVE DUNBAR: Next will be

11 Representative Topper.

12 REPRESENTATIVE TOPPER: Good afternoon.

13 Dr. Levine, I have a question concerning

14 hospitals and especially in rural districts like my own.

15 Something that we've noticed and I think possibly going on

16 statewide is an issue where we have patients who are being

17 seen in hospitals, that are being treated in hospitals, and

18 at the end of their treatment they're really not able to

19 live on their own or really to be released, but also there's

20 not much more that the hospital can do. There seems to be

21 that in-between stage for hospitals.

22 Is that an issue that we're seeing in terms of

23 patients that are maybe through behavioral health or they've

24 been treated, they've been cared for, but no longer will the

25 hospitals, you know, be reimbursed but there's also nowhere

43 1 to go? Is that a situation that is statewide and, if so,

2 are there any conversations about ways that we can possibly

3 address that?

4 SECRETARY RACHEL LEVINE: Sure.

5 So I think that is an issue statewide. I think

6 that you'll find that hospitals, since for the most part

7 they're paid by DRGs in terms of the diagnosis, are trying

8 to get people better and to discharge them more quickly. I

9 think that that's a general rule in hospitals throughout the

10 state. And I think it's more a challenge in rural areas

11 because of lack of other care.

12 I think that other types of facilities are being

13 looked at to take care of those patients, such as

14 rehabilitation hospitals. So you can have rehabilitation

15 for orthopedic issues or rehab hospitals that will take care

16 of cardiac parents, cancer patients, etc.

17 And then also we have an expanding home health

18 industry. And so we regulate all of that. And I think that

19 the goal is that patients would be sent home, but also with

20 home health care or rehab.

21 I think it's a particular challenge in rural

22 areas because there might not be as many home health care

23 agencies in rural areas as there might be in suburban and

24 urban areas and also, you know, in terms of the number of

25 rehab facilities. But I think that the idea is to go from

44 1 acute care to subacute care, whether that's in rehab or at

2 home.

3 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: And

4 I'll only add to that that it's not only will the agencies

5 that are limited, but it's the direct care workers

6 themselves, the individuals who work at those agencies. We

7 have a direct care worker shortage here in Pennsylvania.

8 The Department of Aging as well as Health have

9 participated in putting out some ideas around how to address

10 that shortage. But it's the challenge of having the

11 employees particularly in rural areas who can provide that

12 care in the communities.

13 SECRETARY RACHEL LEVINE: And one more point is

14 one of the reasons why we have a dearth of direct care

15 workers is they don't get paid well. And sometimes they get

16 paid at a minimum wage. So one way to improve that would

17 actually be through the Governor's proposal to increase the

18 minimum wage to a living wage. And that would actually help

19 more people become direct care workers because then they

20 could support their family.

21 REPRESENTATIVE TOPPER: What about within the

22 hospitals themselves? I mean, are we finding that they are

23 short-staffed? Are they fully staffed? I mean, you know,

24 as I look at it, there certainly are options for continued,

25 you know, home care and skilled workers there. But also if

45 1 some of these individuals are already in the facility, if

2 hospitals can also expand a little bit of what they can do,

3 I mean, are they capable of that? Is it just a matter of

4 whether they're getting reimbursed for it or not?

5 SECRETARY RACHEL LEVINE: I think one of the

6 issues that this relates to is rural health hospitals, rural

7 hospitals in general. Rural hospitals are under siege

8 throughout the country and in Pennsylvania because it's very

9 hard for them to survive in that fee-for-service

10 environment.

11 And so that is really the basis of our rural

12 hospital initiative. And thank you for the Legislature and

13 thank all of you for unanimously passing the Rural Health

14 Redesign Center. So this is a very innovative program. It

15 was actually the brainchild of a predecessor, Dr. Karen

16 Murphy, to save rural hospitals so they no longer have to

17 live on a fee-for-service basis and they will work on a

18 global budget which would help them be able to take care of

19 people without having to worry that they're going to have a

20 large deficit and eventually have to close.

21 I mean, we've even seen some hospitals close in

22 the last couple months that are rural hospitals. So we have

23 this initiative. The Rural Health Redesign Center will be

24 up and running by May.

25 REPRESENTATIVE TOPPER: So with that being said,

46 1 real quick, with that initiative, I mean, you just said

2 we've seen some hospitals close. Do you feel that it's just

3 the initiative didn't have time to work or was it simply

4 those were going to close anyway? I mean, is there more

5 that we can do there?

6 SECRETARY RACHEL LEVINE: Well, the goal is to

7 expand the initiative. It's been running one year. And we

8 had five hospitals. We recruited eight more so now there's

9 13 hospitals. The goal is 30 hospitals. We would love your

10 participation in terms of recruiting hospitals to the model.

11 It's takes a real leap to --

12 REPRESENTATIVE TOPPER: Well, you have mine.

13 SECRETARY RACHEL LEVINE: Thank you.

14 REPRESENTATIVE TOPPER: So that's good.

15 SECRETARY RACHEL LEVINE: It takes a real leap to

16 go from the traditional fee for service to a global budget.

17 And we'd love to work with you on recruiting more hospitals.

18 REPRESENTATIVE TOPPER: Thank you.

19 SECRETARY RACHEL LEVINE: Thank you.

20 REPRESENTATIVE TOPPER: Thank you, Mr. Chairman.

21 REPRESENTATIVE DUNBAR: Thank you,

22 Representative.

23 Next will be Representative Comitta.

24 REPRESENTATIVE COMITTA: Thank you, Mr. Chairman.

25 Good afternoon, Madam Secretary and your capable

47 1 team.

2 SECRETARY RACHEL LEVINE: Good afternoon.

3 REPRESENTATIVE COMITTA: I have some questions

4 for Secretary Smith regarding families and individuals

5 impacted by substance abuse. One major reason that people

6 don't seek drug and alcohol treatment is the fear of what

7 their family and friends might say. And I'm wondering what

8 the Department is doing to help decrease this stigma.

9 SECRETARY JENNIFER SMITH: That's a great

10 question. So with some of the Federal funding that we have

11 received over the last several years, we have done some

12 traditional media campaign work in terms of advertising our

13 hotline.

14 We also partnered with Independence Blue Cross

15 and Penn State University on an anti-stigma campaign called

16 Someone You Know, which was a means of recognizing

17 individuals who are in recovery and their stories. And we

18 utilized that platform to have some community conversations

19 across the State talking about stigma in general and

20 educating people about substance use disorder as a disease.

21 And we saw some benefits from all of those

22 things. But our feeling was a little bit like, what's the

23 next step? Where do we go next? And so what we're going to

24 be doing over the next about a year and a half is partnering

25 with an entity called The Public Goods Project and the

48 1 Douglas Pollock Center, which is an addiction research

2 center out of Penn State University on what we're calling a

3 Behavior Change Campaign. And so this is a mechanism of

4 utilizing social media influencers to actually effect

5 behavior change.

6 The Public Goods Project is an entity that did

7 similar work, piloted this with the mental health space and

8 about five other states and saw an 8 percent change in

9 behavior and attitude.

10 So this will be the first time that they're doing

11 a substance use disorder specific campaign but the model is

12 very similar. So it will be about a 15-month endeavor and

13 we're just about ready to kick that off. And it will

14 include an outcome study as evaluated by Penn State

15 University.

16 So in addition to doing the actual campaign

17 itself and partnering with that entity, we'll also have a

18 nice outcome study to accompany it that hopefully other

19 states will be able to benefit from as well.

20 REPRESENTATIVE COMITTA: That sounds great.

21 So following on that, we know that families are

22 severely impacted when their loved one struggles with an

23 addiction, any addiction. What is DDAP doing to support

24 initiatives that aim to support these families?

25 SECRETARY JENNIFER SMITH: Another great

49 1 question. So we just recently put out a funding

2 announcement specifically around offering funding to support

3 families as a result of addiction. So I believe that's

4 still outstanding actually.

5 I'll let Ellen talk about that.

6 DEPUTY SECRETARY ELLEN DiDOMENICO: I'll just

7 give you an update because we're really pretty excited. We

8 had two funding announcements out that closed last week.

9 And we received -- one of them was for exactly that, looking

10 at recovery supports for programs that would also serve the

11 family members, not just those individuals in recovery, and

12 also a second one around employment opportunities for

13 individuals in recovery. Between those two applications

14 that were available, we received over 60 applicants

15 statewide.

16 So it's going to take us a little bit longer to

17 review those than we had hoped. But we think that really

18 speaks very, very well to the interest across the

19 Commonwealth in terms of wanting to support individuals and

20 their families in recovery.

21 REPRESENTATIVE COMITTA: Well, thank you so much

22 for your good work helping the individuals who are suffering

23 from addiction and the families who love them.

24 Thank you.

25 REPRESENTATIVE DUNBAR: Thank you,

50 1 Representative.

2 Next will be Representative Greiner.

3 REPRESENTATIVE GREINER: Thank you, Mr. Chairman.

4 Thank you for coming today, Secretaries. Glad to

5 have you. I'm going to switch gears to a topic that affects

6 government overall and that's regulation. And specifically

7 I want to talk about the surgery centers.

8 I know the last couple years there's been some

9 tax questions on them, but mine is more based on, you know,

10 the ambulatory surgery centers are governed by health rules

11 that were created back in the 1990s. So, you know, we're

12 talking about 25 years ago.

13 And since that time, you know, the regulatory

14 process doesn't seem to be quite as nimble. I mean, these

15 surgery centers have been -- you know, there's great

16 advances in technology, which you know. And I do think they

17 serve an advantage here in the Commonwealth.

18 And just two years ago, two, two and a half years

19 ago, the Department of Health and the surgery centers were

20 collaboratively updated, you know, a piece of regulation,

21 extending the length of stay in a surgery center. And, you

22 know, for a long time Pennsylvania has been very restrictive

23 in this area.

24 I'm just wondering, you know, Medicare is not

25 quick to approve certain procedures. We have people from

51 1 the Commonwealth that are going to -- you know, I live in

2 Lancaster County. They go to Maryland or Delaware or

3 something like that.

4 And I was just wondering, you know, unless you

5 know otherwise, it seems like they've been pretty

6 successful. The infection rates are low and what have you.

7 Is there going to be an opportunity moving forward for the

8 Department to work with the Legislature and also, I guess,

9 the industry to help with some of the regulatory challenges

10 that are occurring right now?

11 SECRETARY RACHEL LEVINE: I'll start.

12 You're entirely correct. The last date of staff

13 regulations were promulgated in 1999 and so things have

14 changed in 20 years, 21 years, so it is really challenging.

15 We have a very ambitious regulatory agenda. The

16 hospital regulations have not been updated since 1984. And

17 the nursing home or long-term care regulations have not been

18 updated since the late '90s as well. And we also have to

19 promulgate the final medical marijuana. So we have a very

20 ambitious regulatory agenda.

21 ASF is in that queue but, as you know, as you

22 said, the regulatory process is not nimble. To that end, we

23 have a very robust exceptions process. And I'm going to let

24 Sarah kind of talk about that process and how we've improved

25 that process.

52 1 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Yes.

2 So there's a unique piece of the Health Care

3 Facilities Act that allows the facility to request an

4 exception to the regulation that moves through a process at

5 the Department of Health; for example, vascular procedures

6 or something that was of great interest to ambulatory

7 surgical facilities. So we created a document that outlined

8 really what we'd be seeking in an exception so that a

9 facility could use that as a road map as they were preparing

10 that documentation to streamline that process and turn those

11 around quicker for facilities.

12 Through that effort as well as through the

13 Governor's commitment to lean in performance improvement, we

14 actually have asked our Director of Operational Excellence,

15 Brian Lentes, to apply lean principles to the exception

16 process. That project is ongoing right now. This way we

17 can ensure that when facilities need to, as we work to

18 promulgate new regulations, use that process to get those

19 answers quickly, that they are clear, and they can start

20 doing procedures that are deemed appropriate to be done

21 ambulatory.

22 REPRESENTATIVE GREINER: When did that start? I

23 mean, when did that process start because, I mean -- just

24 recently probably?

25 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Well,

53 1 the exceptions process existed. It's from the Health Care

2 Facilities Act. The vascular guideline publication was, oh,

3 maybe a year ago or so.

4 REPRESENTATIVE GREINER: Yeah. I was going to

5 say -- but the timetable can be long with Medicare and what

6 have you. You know what I'm saying? People say they want

7 something done. If it's not done in a timely fashion,

8 people want to go elsewhere to get their procedure or

9 surgery done or something like that.

10 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Yes.

11 The pain and mechanism would be beyond the

12 Department of Health. It would be CMS who is saying they're

13 not going to pay for a procedure in this particular

14 location. That's beyond us. But we have the regulatory

15 ability to provide an exception when appropriate.

16 REPRESENTATIVE GREINER: Like I said, when I

17 asked the question, I mean, I think you answered me. It's

18 hospitals. It's surgery centers. It's everything. It's

19 somewhat the nature of government. We tend to be more -- it

20 takes us time to steer this battleship.

21 I appreciate the answers and you taking the time

22 to be here today. Thank you.

23 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Sure.

24 REPRESENTATIVE GREINER: Thank you, Mr. Chairman.

25 SECRETARY RACHEL LEVINE: I just want to say that

54 1 we have implemented Act 70 of 2017 and we're pleased to work

2 with the Legislature on other innovative processes.

3 REPRESENTATIVE DUNBAR: Thank you.

4 Next will be Representative Kinsey.

5 REPRESENTATIVE KINSEY: Thank you, Mr. Chairman.

6 Good afternoon, Secretaries. I want to direct my

7 question to Secretary Levine. And I want to talk about

8 hospitals. I know that the topic came up earlier, but I

9 want to talk a little bit more specific.

10 There's been great concerns I think we're seeing

11 across the Commonwealth where we're seeing hospitals

12 closing. Of course, I represent the city of Philadelphia

13 and there was great concern when Hahnemann announced that

14 they were closing. I understand that in addition to

15 Hahnemann, you have Elwood City, you also have UPMC, that's

16 proposing, I think, to close later this year. And then we

17 just found out recently that Mercy in Philadelphia is

18 talking about partial services.

19 And, Secretary Levine, I think that my question

20 is, as we see this shift where more and more hospitals are

21 closing, do you believe that the closure is probably due to

22 some extent with Medicaid rates? Is that the primary driver

23 of these closures? That's one part of the question.

24 Then the second part is, I know that -- and again

25 I can refer to the city of Philadelphia with the purchasing

55 1 of the Hahnemann facility. Do you think that we need title

2 regulations to ensure that viable entities are buying our

3 Pennsylvania hospitals?

4 And I think lastly, you know, I mean, it's easy

5 for us to speculate, but I guess my question to you,

6 especially with your expertise, are we just seeing like the

7 market adjusting in regards to increased emphasis on

8 outpatient services as opposed to inpatient services? If

9 you can sort of talk on those topics, please.

10 SECRETARY RACHEL LEVINE: Sure.

11 I think all of those things are true. And thank

12 you for your question. I think that when you look at

13 hospital closures, you do have to look at some specifics.

14 So I think the problems facing rural hospitals such as UPMC

15 Sunbury and some other rural hospitals is different than

16 Hahnemann in urban Philadelphia.

17 I think that the rural hospitals are going to

18 struggle in a fee-for-service environment. And we

19 eventually want to sign as many as possible to our rural

20 health initiative so that they will be actually on a global

21 budget so they don't have to work on a fee-for-service basis

22 and can look at more population health.

23 In terms of urban hospitals, I think that urban

24 hospitals that are predominantly public hospitals, Medicaid

25 hospitals are going to struggle. We have no public

56 1 hospitals in Pennsylvania. I trained in New Orleans at

2 Tulane where I did my medical school training. And they had

3 Charity Hospital at that time. Charity had closed and now

4 they have a new Charity Hospital. Chicago has Cook County

5 and Atlanta has Grady. California -- LA has LA. They are

6 public hospitals and they don't really have -- they're

7 supported by the City and the State. And they don't have to

8 worry about billing. We don't have any public hospitals

9 like that supported by the City and the State.

10 And so it's going to be very challenging for

11 hospitals such as, obviously, Hahnemann, to live in that

12 environment. So I think that innovative payment reform will

13 be a very interesting discussion including, of course, the

14 Department of Human Services and the Department of Health

15 and other agencies about different ways that can happen.

16 I think that shift, in addition, from inpatient

17 to outpatient also is something that needs to be looked at.

18 There are hospitals in some suburban and rural areas that

19 are looking to become more, quote, unquote, micro hospitals

20 or small-footprint hospitals. One health care agency calls

21 them neighborhood hospitals, one health care system where

22 they have an ER, they have outpatient facilities, and then

23 they have a smaller inpatient footprint. And we actually

24 put out guidance about, quote, unquote, micro hospitals.

25 And I think that's interesting if you're going to look at an

57 1 urban area.

2 I also think that the issues in terms of private

3 equity for-profit hospitals in an urban area like

4 Philadelphia is challenging. And I think that -- and the

5 same with Elwood City. So I think that -- I mean there are

6 some for-profit hospitals that do a fantastic job. But when

7 private equity gets involved and they're really looking to

8 squeeze out a profit and there have been some -- I want to

9 be politically correct here -- bad actors that have been

10 involved, specific owners, I think that's a real challenge

11 and I think we'd be pleased to work, you know, with the

12 Governor's Office and the Legislature on ways to regulate

13 that better.

14 REPRESENTATIVE KINSEY: I appreciate you sharing

15 that. And, Dr. Levine, Einstein Hospital sits in my

16 Legislative District. However, they also closed years ago

17 what was called Germantown Hospital and Women's Hospital.

18 You know, they're surrounding sort of like the northwest

19 section of Philadelphia. I just think that it would be

20 incumbent upon us to maybe have these discussions to look at

21 the future, especially as we see this trend of hospitals

22 closing.

23 So I appreciate your offer to sit down. You

24 know, maybe we can gather some of the -- and I'm thinking

25 some of the urban hospitals at least to start. I recognize

58 1 this concern is with rural hospitals as well but maybe bring

2 in some of the urban hospitals to sort of see if there's a

3 collective fashion where we can work together --

4 SECRETARY RACHEL LEVINE: Absolutely.

5 REPRESENTATIVE KINSEY: -- and maybe look at, you

6 know, some public support to create even a footprint of a

7 public hospital. But thank you very much for your sharing

8 that.

9 SECRETARY RACHEL LEVINE: Of course.

10 REPRESENTATIVE KINSEY: Thank you, Mr. Chairman.

11 REPRESENTATIVE DUNBAR: Thank you,

12 Representative.

13 Next will be Representative White.

14 REPRESENTATIVE WHITE: Thank you very much,

15 Secretary, for being here with us today.

16 I just had a question regarding the work that

17 you're doing when it comes to the Pennsylvania

18 Confidentiality Needs Assessment and the Stakeholder

19 Education Project. Does that sound familiar?

20 SECRETARY JENNIFER SMITH: Yes.

21 REPRESENTATIVE WHITE: Okay. Great.

22 How does the -- you know, how much does this

23 project cost as of right now? What's the projection?

24 SECRETARY JENNIFER SMITH: So in terms of the way

25 that this project is being carried out, it's actually being

59 1 funded through Bloomsburg Philanthropies as part of the $10

2 million of resources that they dedicated to Pennsylvania

3 over three years. So the staff member dedicated to this

4 project is actually funded through those dollars. So it is

5 not costing the Commonwealth staff dollars in order to

6 undertake this effort.

7 REPRESENTATIVE WHITE: When the project is

8 complete and the results from the needs assessment are

9 developed and the education materials, I think, that are

10 supposed to be produced from it, are those going to be

11 reports that are Pennsylvania-department-produced materials?

12 SECRETARY JENNIFER SMITH: Yes.

13 So let me explain a little bit about how this

14 arrangement works.

15 REPRESENTATIVE WHITE: Okay.

16 SECRETARY JENNIFER SMITH: So the staff member

17 that is working on this project was actually jointly hired

18 by Vital Strategies, which is the organization that's

19 helping to implement some of the Bloomsburg projects, but

20 jointly hired by Vital Strategies and the Department of Drug

21 and Alcohol Programs. So that individual actually sits in

22 our office and reports to us on a daily basis.

23 REPRESENTATIVE WHITE: Okay.

24 SECRETARY JENNIFER SMITH: So even though she's

25 being funded through Bloomsburg Philanthropies, her work is

60 1 being directed by the Department and, of course, guided by

2 Vital Strategies.

3 REPRESENTATIVE WHITE: Okay.

4 SECRETARY JENNIFER SMITH: So at the end of her

5 work in terms of gathering information and listening to

6 stakeholder input, she will be using all of that information

7 in conjunction with the George Washington Report, which is

8 already available, that analyzes our current confidentiality

9 regulations around substance use disorder. She will be

10 pulling all of those things together and providing to us

11 some recommendations for continued action.

12 So as a result of her project, we will have a

13 menu of options to move forward with. And those options

14 could be anything from we simply need to provide --

15 REPRESENTATIVE WHITE: I guess I just wanted to

16 make sure that I understood correctly in terms of the end

17 product.

18 SECRETARY JENNIFER SMITH: Sure.

19 REPRESENTATIVE WHITE: You know, the end result

20 of your coordination with this organization who we know --

21 you know, obviously, you're sharing with us that it's

22 Bloomsburg funded and, you know, I'd like to hear about your

23 efficacy concerns in terms of the fact that the man is

24 running for President and if maybe the influence of policy

25 within our own Pennsylvania departments is of any concern to

61 1 you. But as it pertains to these, the end products, the

2 materials that are going to be produced by your Department

3 and then effectively put out to the public, you know --

4 these are going to be official documents from your

5 Department?

6 SECRETARY JENNIFER SMITH: Yes.

7 REPRESENTATIVE WHITE: And are they going to tell

8 anybody, the public, the Vital Strategies that had influence

9 over the end product?

10 SECRETARY JENNIFER SMITH: I'm certainly not a

11 communications or a copyright expert. But my understanding

12 is that any materials developed would be branded both with

13 our Department's logo as well as Vital Strategies.

14 REPRESENTATIVE WHITE: Okay.

15 And any reference to Bloomsburg involved in that

16 as well?

17 SECRETARY JENNIFER SMITH: That would be up to my

18 legal team. I don't know the answer to that question. I'm

19 not a lawyer.

20 REPRESENTATIVE WHITE: Okay. No problem. I was

21 just wondering.

22 Then I have one other question for you regarding

23 Kensington in Philadelphia.

24 SECRETARY JENNIFER SMITH: Sure.

25 REPRESENTATIVE WHITE: You know, it's my

62 1 understanding that there are counselors in Lancaster County

2 who are actually getting their student loans paid off within

3 two years. And these are counselors for drug- and

4 alcohol-dependent persons. But unfortunately when I called

5 to find out what percentage of those weekly calls that you

6 guys do with all of the emergency funding from the Federal

7 Government when it comes to the opiate epidemic, when I

8 called up to find out what percentage of your calls are

9 dedicated to Kensington, the open-air drug market in

10 Philadelphia, I was told zero, that there is zero amount of

11 time specifically dedicated during those calls that are for

12 Philadelphia's open air-drug market. And that raised major,

13 major concerns for me.

14 I just wanted to hear what your response to that

15 is and what is going on in terms of Philadelphia and the

16 drug epidemic and how you're -- you know, how you're making

17 sure that those dollars are being utilized effectively,

18 especially when people's student loans are getting paid off

19 that aren't even people -- you know, when you can utilize

20 those dollars more efficiently to get more people helping

21 our drug-dependent and drug-addicted persons in

22 Philadelphia.

23 SECRETARY JENNIFER SMITH: Sure.

24 So there's a lot to unpack in that question that

25 you just asked.

63 1 REPRESENTATIVE WHITE: Well, there's a lot of

2 concerns, so thank you.

3 SECRETARY JENNIFER SMITH: We'd be happy to maybe

4 schedule an additional meeting with you to talk through

5 whatever I can't answer very quickly. So we'll be happy to

6 send you some information around the loan repayment program

7 so that you can understand what that is and what that does.

8 But more specifically, your question around -- I believe

9 you're referring to the Governor's Opioid Command Center --

10 REPRESENTATIVE WHITE: Yes.

11 SECRETARY JENNIFER SMITH: -- which was

12 established as part of the Disaster Declaration and meets

13 every Monday, if not in between, as required. So there is

14 no dedicated funding specifically to a jurisdiction as part

15 of those calls. There are 17 different State agencies that

16 participate every week on those phone calls.

17 REPRESENTATIVE WHITE: Um-hmm.

18 SECRETARY JENNIFER SMITH: So the issues that we

19 discuss depend on the priorities that we have for discussion

20 purposes. I can assure you that the bulk of the topics that

21 we are discussing and how funding is spent would absolutely

22 directly benefit Kensington or Philadelphia more broadly.

23 I can also tell you that outside of those calls,

24 our Department spends a very significant amount of time

25 talking about how do we help the individuals who live in the

64 1 Philadelphia area, because that is Ground Zero for the

2 opioid crisis. So taking a look at how their dollars are

3 currently being spent, where all of the dollars are being

4 spent, how they're being purposed, and making sure that we

5 can assist the city in directing those priorities.

6 So there's lots of time and conversations around

7 that topic, not necessarily just in the Opioid Command

8 Center calls though.

9 SECRETARY RACHEL LEVINE: And if I may add, I

10 mean, Philadelphia, of course, has its own Health Department

11 which does not report to the Pennsylvania Health Department,

12 but we talk with Commissioner Farley every month to

13 coordinate.

14 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Just

15 two weeks ago there was a specific presentation at the

16 Command Center, almost the entire meeting, from a gentleman

17 who works exclusively in Kensington. And it was a very

18 important presentation. You know, he really talked about

19 the great majority of overdoses happening in that

20 eight-block area, that part of the city. So that

21 conversation did happen at the Command Center just recently.

22 REPRESENTATIVE WHITE: Thank you.

23 REPRESENTATIVE DUNBAR: Thank you.

24 Next will be Representative Kim .

25 REPRESENTATIVE KIM: Thank you, Mr. Chairman.

65 1 I have one question and it's directed to Dr.

2 Levine.

3 SECRETARY RACHEL LEVINE: Okay.

4 REPRESENTATIVE KIM: Back in January I saw an

5 article that caught my eye. And I wanted to read a small,

6 short excerpt of it and then get your thoughts on it.

7 SECRETARY RACHEL LEVINE: Okay.

8 REPRESENTATIVE KIM: It says, a new study

9 suggests that raising the minimum wage might lower the

10 suicide rate. The Federal minimum wage is $7.25, though

11 many states have set it higher. Between 1990 and 2015,

12 raising the minimum wage by $1 in each state might have

13 saved more than 27,000 lives according to a report published

14 back in January in the Journal of Epidemiology and Community

15 Health. An increase of $2 in each state's minimum wage

16 could have prevented more than 57,000 suicides. This is a

17 quote. This is a way that you can, it seems, improve the

18 well-being of people working at lower-wage jobs and their

19 dependents, says John Kaufman, the lead author on the study

20 and an epidemiology doctor of students at Emery University.

21 Without you looking at the study, can you give me

22 your take on the correlation between poverty and public

23 health care?

24 SECRETARY RACHEL LEVINE: Sure. Thank you.

25 I think there's a significant correlation and

66 1 it's been shown in many different avenues between poverty

2 and public health. It has to do with what we would call

3 social determinants of health are the other aspects of

4 society that we don't usually think of -- we usually talk

5 about hospitals, we talk about health systems, we talk about

6 medicines -- that significantly impact individuals' health.

7 One is economic security and economic opportunity. The

8 others would be nutrition, the environment, housing,

9 schools, transportation.

10 All of those actually to me are health issues

11 because they impact public health. There are studies after

12 studies that have been published that show an association

13 between poverty and lack of economic opportunity with

14 significant negative health outcomes, both from a mental

15 health point of view, depression, suicide, substance abuse,

16 other negative mental health issues, but also other issues,

17 heart disease, lung disease, etc.

18 So that's why to me increasing the minimum wage

19 to a living wage is actually a health issue. Everything

20 kind of comes down to public health.

21 REPRESENTATIVE KIM: Thank you for your answer.

22 REPRESENTATIVE DUNBAR: Thank you,

23 Representative.

24 Next will be Representative Lawrence.

25 REPRESENTATIVE LAWRENCE: Thank you, Mr.

67 1 Chairman.

2 Thank you, Secretary Levine. The Department of

3 Health is responsible for overseeing Pennsylvania's Medical

4 Marijuana Program, including licensing growers and

5 dispensaries. The process by which licenses to grow and

6 sell medical marijuana were issued has been shrouded in

7 secrecy. The Department of Health has waged a yearlong

8 crusade against right-to-know requests asking how the State

9 chose to hand out these very valuable licenses.

10 A January 29th PennLive article detailed the

11 Department of Health's latest appeal to the Pennsylvania

12 Supreme Court. This time the order of the Commonwealth

13 Court issued back in June ruled the Office of Open Records

14 was justified in requiring the Department that you oversee

15 release names and information regarding those running and

16 financing medical marijuana operations and the identities of

17 the individuals who review the first application of medical

18 marijuana permits.

19 I think the Department's position here is really

20 remarkable. Why the veil of secrecy? What is the

21 Department of Health trying to hide by refusing to release

22 information that multiple courts have ordered sunshine to

23 the general public?

24 SECRETARY RACHEL LEVINE: So I'll defer to my

25 attorneys in terms of some of the specific legal issues. A

68 1 lot of it has to do with the contracts and the applications

2 and the type of, quote, unquote, proprietary information

3 that are in those applications, that if we released the

4 information, if we released a lot of the names, then we

5 could get sued by them.

6 My understanding from our attorneys is that in

7 some ways if we release the information, we'd get sued, and

8 if we didn't release the information, we'd get sued. And so

9 the overall tenor has --

10 REPRESENTATIVE LAWRENCE: With all due respect,

11 the State is sued all the time for all sorts of reasons.

12 SECRETARY RACHEL LEVINE: I understand.

13 REPRESENTATIVE LAWRENCE: And the concept that --

14 I mean, we have folks bid for all sorts of contracts: The

15 Lottery, PennDOT, anything, you name it. I mean, wouldn't

16 you agree that a State license to grow or dispense medical

17 marijuana is of significant value?

18 SECRETARY RACHEL LEVINE: A State contract to

19 grow or dispense medical marijuana?

20 REPRESENTATIVE LAWRENCE: State license.

21 SECRETARY RACHEL LEVINE: State license.

22 REPRESENTATIVE LAWRENCE: That's of significant

23 value, wouldn't you agree?

24 SECRETARY RACHEL LEVINE: Yes.

25 REPRESENTATIVE LAWRENCE: All right.

69 1 So isn't it in the public interest to know who

2 reviewed the applications, if not simply to ensure there

3 wasn't self-dealing?

4 SECRETARY RACHEL LEVINE: We do not usually

5 release the names of the reviewers of different contracts.

6 So this is really -- our process followed all of the same

7 processes that any type of contract has, any type of request

8 for applications, that we have different State officials

9 review them. We don't routinely release the names of those

10 State officials.

11 REPRESENTATIVE LAWRENCE: But I believe --

12 SECRETARY RACHEL LEVINE: But in the end, in

13 terms of releasing the names, in the end, we did release the

14 names. The Court asked us to release the names of the

15 reviewers and we did. So there are a couple of different

16 lawsuits that have happened. When the Court asked us to

17 release the name of the reviewers, we did.

18 In terms of some of the proprietary information

19 in the contracts that have also been -- and the

20 applications, a lot of it had been redacted by the

21 applicants. And the view from our attorneys has been that

22 that would violate their confidentiality and so the State

23 has taken --

24 REPRESENTATIVE LAWRENCE: So I read that in the

25 article. I thought that was even more remarkable. The

70 1 State is allowing the applicants to say what should and

2 shouldn't be shielded from the Pennsylvania taxpayers,

3 citizens, and the Office of Open Records?

4 SECRETARY RACHEL LEVINE: Again, I'll defer to my

5 attorneys.

6 REPRESENTATIVE LAWRENCE: Don't -- you're in

7 charge of this Department. I think that's a remarkable

8 statement. Why the latest appeal to the Supreme Court? Why

9 wouldn't you simply release the information that multiple

10 courts and the Office of Open Records have repeatedly asked

11 you to release?

12 SECRETARY RACHEL LEVINE: We'd be glad to meet

13 with you to discuss that with our attorneys.

14 REPRESENTATIVE LAWRENCE: I think that's a

15 remarkable statement.

16 Mr. Chairman, I have no more questions.

17 REPRESENTATIVE DUNBAR: Thank you,

18 Representative.

19 We'll continue our journey across the back row

20 and go to Representative Sanchez.

21 REPRESENTATIVE SANCHEZ: Thank you, Mr. Chairman.

22 Madam Secretary, I have several questions for

23 you. I want to start with the WIC funding. As you probably

24 know, it's been declining due to declining participation,

25 federally funded to the tune of about 3.7 million since

71 1 Fiscal Year 2014. Does the Department have any specific

2 plans to engage the eligible mothers and children and kind

3 of reverse that trend, assuming the need is probably there

4 and the importance of nutrition?

5 SECRETARY RACHEL LEVINE: Thank you.

6 As you pointed out, WIC is such an important

7 program. What can be more important than providing

8 nutrition for pregnant women, infants, and children. And

9 remember, I'm a pediatrician in my initial training so I

10 know how absolutely critical that is.

11 We have been working very hard to continue an

12 excellent WIC Program in Pennsylvania. As you noted though,

13 the number of participants, the number of different

14 individuals in Pennsylvania participating in the program,

15 has declined. Unfortunately, that's actually a national

16 trend. The WIC participation has declined all over the

17 country.

18 A lot of ideas about why that's so. Some of it

19 might be more patients have Medicaid and can get other care

20 in other ways, other types of benefits, but we think that

21 there's other reasons as well. I mean, one thing that

22 actually in the last three or four years that's concerning

23 is that many individuals are afraid to apply for any type of

24 Federal benefit because they will be on a Federal database

25 and then ICE can access that database and it could be

72 1 immigration issues, so you don't have to be a citizen

2 actually to get WIC.

3 But we are working with our 24 WIC agencies to

4 try to recruit more patients. We have programs to try to

5 recruit more patients in. And more families in terms of

6 that are affected by the opioid crisis. We have just put

7 out our eWIC Cards so that you no longer have to have what a

8 lot of people thought were stigmatizing WIC checks that

9 everybody could see. Now it looks like any other type of

10 credit card. And we are working with our WIC agencies to

11 try to improve participation.

12 REPRESENTATIVE SANCHEZ: Thank you for that

13 answer. Thank you for those efforts.

14 I'm going to switch gears here to an entirely

15 different topic.

16 SECRETARY RACHEL LEVINE: Sure.

17 REPRESENTATIVE SANCHEZ: Jumping back to medical

18 marijuana. I've been told by some of the dispensaries that

19 they're unhappy with your software system, the MJ Freeway

20 Software System. Is there a timeline on when that contract

21 is up, when it might be out for bid next? Is there

22 something more functional, you know, and also something that

23 allows them to calculate sales tax? There's been a whole

24 litany of complaints.

25 SECRETARY RACHEL LEVINE: So we have also heard

73 1 the complaints about MJ Freeway. We work really closely

2 with MJ Freeway to try to make sure that it is an efficient

3 and functional system. I'll have to check and see when the

4 next RFA is for our system and we will put that out for bid

5 again. But I think that the people that bid at the time, MJ

6 Freeway won the bid. So we are working with them to improve

7 their efficiency and to improve their performance and will

8 continue to try to hold them accountable.

9 REPRESENTATIVE SANCHEZ: Thank you.

10 And then switching to the consumer or the patient

11 side of that equation. We've also heard complaints from

12 some of the patients that their cards don't scan properly in

13 the stores, they have difficulties with the application

14 process, some of which, you know, they're being assisted

15 with by the dispensaries, but they're also being turned away

16 and they have trouble reaching the Call Center at times.

17 Are there efforts or reinvestments that the

18 Department is exploring?

19 SECRETARY RACHEL LEVINE: Yes.

20 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Do you

21 want me to answer that?

22 SECRETARY RACHEL LEVINE: Yes.

23 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Yes,

24 thank you for bringing those questions up.

25 I think it's important to put this into context,

74 1 that the Medical Marijuana Program here in Pennsylvania has

2 provided really important medicine to hundreds and thousands

3 of Pennsylvanians. So the program grew rapidly and quickly

4 in two years. We have individuals who work in our Bureau

5 with the Medical Marijuana Program whose job is specifically

6 to help advocate for patients and be there as a resource.

7 And we are working right now to bring on a new

8 call center vendor who will really be that front door to

9 help resolve what might be more minor issues, password

10 reset, challenges understanding how to navigate a website if

11 you're not very web savvy so that that front door is right

12 there for patients, and that only if necessary to be

13 elevated to that level Tier 2, which is where most folks are

14 starting right now.

15 So we're hoping with that front door, people will

16 have a more customer service friendly experience and those

17 questions and challenges that they're having will be

18 resolved quickly.

19 REPRESENTATIVE SANCHEZ: Thank you.

20 And I see my time has expired. So thank you for

21 those answers. I appreciate it.

22 REPRESENTATIVE DUNBAR: Thank you.

23 Next will be Representative Delozier.

24 REPRESENTATIVE DELOZIER: Thank you, Mr.

25 Chairman.

75 1 Thank you all for being here and answering the

2 many questions.

3 I have a question, Secretary Smith, dealing with

4 drug and alcohol.

5 SECRETARY JENNIFER SMITH: Okay.

6 REPRESENTATIVE DELOZIER: Obviously with the

7 opioid crisis, as Representative Rothman mentioned earlier,

8 in Cumberland County we're very proud. We have both the

9 Drug Court and the Opioid Court which we believe work very

10 well.

11 But when I was taking a look at some of the

12 numbers across the board, because some of the measurements

13 that you had, the program measures, which I think is great

14 that we're able to measure what it is that's being -- who is

15 being served, for outpatient treatment, I was taking a look

16 at the three-year comparative. We have '17-'18. There were

17 -- the typical length of stay was 77 days. And for '18-'19

18 and '19-'20, it was 44 days. So my question is, is this

19 good or bad? because to me I would think that the additional

20 treatment -- are people just not finishing? Why the change?

21 It's pretty significant. It's like 43 percent, that

22 reduction, and from my understanding, treatment needs longer

23 time in. So why the step back?

24 SECRETARY JENNIFER SMITH: First, I appreciate

25 that you're looking at the program measures. That's very

76 1 exciting to us.

2 Unfortunately, what I have to share is you have

3 to really be cognizant of what you're looking at with our

4 program measures.

5 REPRESENTATIVE DELOZIER: Okay.

6 SECRETARY JENNIFER SMITH: These program measures

7 are specific to the individuals for which we provide

8 funding, which would be the uninsured population. So this

9 is not average length of stay or average days in treatment

10 for individuals on the Medicaid Program or for individuals

11 with private insurance. Our Department does not have access

12 to those numbers.

13 REPRESENTATIVE DELOZIER: Okay.

14 SECRETARY JENNIFER SMITH: In some cases some of

15 the Medicaid data is actually reported under the Department

16 of Human Services under some of the Medicaid data. There is

17 some information there. This information is very specific

18 to just the clients that are funded through our State

19 funding or our Federal Block Grant funding.

20 REPRESENTATIVE DELOZIER: Okay.

21 SECRETARY JENNIFER SMITH: That's why the trends

22 can look a little funny because sometimes if more and more

23 individuals are enrolling in the Medicaid Program and our

24 population is diminishing or perhaps we're only paying for

25 two or three days' worth of treatment for an individual and

77 1 then they're flipping over to a Medicaid funded service,

2 that can really throw off some of the averages that you see

3 here.

4 REPRESENTATIVE DELOZIER: Okay. But still the

5 ability to -- so basically then if we have this data, it's

6 not able to -- because I'm looking at 77 to 44, assuming the

7 same. And so what you're telling me is that that's

8 irrelevant so it doesn't matter what we do year to year

9 because it's never going to be the same audience?

10 SECRETARY JENNIFER SMITH: It is very difficult

11 to utilize program measures that we have access to as a

12 department to paint the entire picture for the drug and

13 alcohol treatment system.

14 REPRESENTATIVE DELOZIER: Okay.

15 SECRETARY JENNIFER SMITH: Because we do not have

16 access to full data that would paint the entire private

17 insurance and Medicaid pictures.

18 REPRESENTATIVE DELOZIER: Okay. Because I

19 thought the Centers of Excellence -- the whole idea was to

20 get longer levels -- or lengths of treatment.

21 SECRETARY JENNIFER SMITH: Yes.

22 REPRESENTATIVE DELOZIER: And so now we're

23 showing that they're getting less time?

24 SECRETARY JENNIFER SMITH: Yes. That's correct.

25 REPRESENTATIVE DELOZIER: Okay.

78 1 SECRETARY JENNIFER SMITH: So the Centers of

2 Excellence are actually administered through the Department

3 of Human Services.

4 REPRESENTATIVE DELOZIER: Okay.

5 SECRETARY JENNIFER SMITH: And so their data

6 would be reflected through the Medicaid data. And they have

7 data to show that lengths of engagement have been longer as

8 a result of those programs.

9 REPRESENTATIVE DELOZIER: Okay.

10 And one other question before time runs out here.

11 The individual that's in recovery -- and I know that

12 Secretary Levine talked about the medical treatment. So I

13 just want to clarify something. Is the -- an individual in

14 treatment, recovery, are they required to maintain a certain

15 amount of outpatient time and treatment in order to continue

16 getting MAT or are they able to, like, just go to one

17 counseling session, kind of fudge it a little bit, and then

18 still receive the MAT?

19 SECRETARY JENNIFER SMITH: So, again --

20 REPRESENTATIVE DELOZIER: Are they required to

21 get -- continue counseling for a duration?

22 SECRETARY JENNIFER SMITH: Sure. I can

23 understand what you're asking. It's important to remember

24 that we're talking about a medication which could be

25 prescribed by a primary care physician or it could be

79 1 administered through what we call a licensed treatment

2 provider. So there are licensing requirements through our

3 Department if they are medications being administered in

4 those licensed facilities. There are requirements around

5 counseling.

6 If medication, however, is being prescribed to an

7 individual with a substance use disorder outside of our

8 licensed facilities, we would not have jurisdiction over

9 monitoring whether there are any requirements by that

10 provider in terms of issuing that prescription to a patient.

11 REPRESENTATIVE DELOZIER: Okay.

12 Because the whole point as we move through this

13 is that, you know, there's resources out there and we want

14 people to get the right treatment in order to break the

15 cycle.

16 SECRETARY JENNIFER SMITH: Absolutely.

17 REPRESENTATIVE DELOZIER: And not be addicted to

18 drugs or alcohol.

19 And I just would put a plug in there before time

20 runs out as to -- with the Drug Courts. We've been very

21 proud of what Judge Mazlin and Judge Brewbaker have been

22 able to do within Cumberland County. And I've sat in on a

23 lot of those graduations for the Drug Courts and it's pretty

24 amazing to watch how low some folks will have to go in order

25 for them to decide to change their lives so I would advocate

80 1 for those types of programs.

2 Thank you.

3 REPRESENTATIVE DUNBAR: Thank you,

4 Representative.

5 Next will be Representative Schweyer.

6 REPRESENTATIVE SCHWEYER: Thank you, Mr.

7 Chairman.

8 Secretaries, how are you all today? Thank you

9 all for being here.

10 At this point in time in the hearing, I think all

11 of us are playing a little cleanup with a couple of random

12 things. So three things I would like to quickly touch upon

13 if I could.

14 First, I represent the city of Allentown and

15 Allentown is one of four municipal health bureaus that we

16 have in the Commonwealth. In fact, three of the four come

17 from Northeast PA, with Bethlehem and Wilkes-Barre joining

18 the city of York. Years ago, from my time on City Council,

19 I remember that our per capita total was about $7.50 between

20 Act 315 and Act 12 for support for our local health bureau.

21 If the information I got today was correct, we're

22 down to about $4.50 per capita. A city the size of

23 Allentown, that translates to about $360,000 less for our

24 health bureau operations.

25 Now, I talked to our director today. I

81 1 understand that they're applying for categorical grants to

2 do more and more stuff. Vicky Kistler is as good as they

3 come and she's really pushing the agenda as much as she can.

4 But at the same time, there's only so much that they can do

5 through grants. And the remainder of that $360,000

6 reduction over time, not in the last budget to be clear, is

7 being backfilled by local real estate taxes.

8 So it's one of those things that -- if my numbers

9 are correct, about 40 percent of all Pennsylvania citizens

10 are covered under a local and county health bureau, not the

11 State, yet the State support for two out of every five

12 Pennsylvanians, including every Allentown resident, is

13 dropping.

14 Is there anything that we should be doing moving

15 forward to try to invest in our local county health bureaus?

16 SECRETARY RACHEL LEVINE: So you're correct.

17 I mean, there are six county and four Health

18 Departments, of course, and Allentown is one. And really

19 since 2011 they have not been fully funded under the formula

20 of Act 315. And, you know, if the Department of Health

21 works with them to the best of our ability in terms of

22 funding challenges, we participate with them and support

23 them in terms of finding CDC grants and other types of

24 Federal grants to support activities and actively work with

25 them, actually Pennsylvania is about 42nd among 50 states in

82 1 terms of public health funding both for us and our community

2 municipal Health Departments. We would be pleased to have

3 discussions with the Legislature in terms of more specific

4 funding for public health in general, including for our

5 county municipal Health Department partners.

6 REPRESENTATIVE SCHWEYER: Well, count me in on

7 those conversations as a matter of not only local concern

8 for Allentown but also all of us. Allentown residents

9 certainly eat in suburban areas and vice versa and food

10 inspections, not to mention lead, STD prevention, go right

11 down the line. All the things that our county health and

12 local health bureaus are doing are very important and then

13 take the pressure off of you to be able to deliver those

14 services more effectively. So I would welcome that

15 conversation.

16 Moving forward, again, Part 2 of my three

17 unrelated questions. I'm going to say the Master Settlement

18 Agreement funding for tobacco prevention and control is

19 still at 4.5 percent, if I'm not mistaken, at $14.7 million

20 I think is the number.

21 Can we talk about that a little bit there?

22 Should we be doing more for tobacco cessation using the MSA

23 dollars since that's sort of what it was originally

24 earmarked for?

25 SECRETARY RACHEL LEVINE: Well, the Tobacco

83 1 Program funds many things. Overall, I think that we have

2 good funding in terms of tobacco prevention. We have many

3 different programs for tobacco cessation and prevention. We

4 continue to make strides. We're so pleased to collaborate

5 with the Legislature and Tobacco 21. Who would have known

6 that the Federal Government, you know, a month later would

7 sign Tobacco 21 for the entire United States.

8 That's such a significant step for Pennsylvania

9 and the entire country in terms of tobacco prevention. Of

10 course, we have lots of challenges in terms of youth vaping.

11 Tobacco 21 applies to vaping but there are some new

12 challenges in terms of that that we would be pleased to work

13 with you on.

14 So it's not as much of a funding issue than it

15 is, you know, working to limit tobacco use and nicotine use

16 through vaping in young people.

17 REPRESENTATIVE SCHWEYER: Unless you're one of

18 those organizations that also relies on it, which some of

19 our organizations do. But I appreciate that. I'm happy to

20 work with you on that item. I have two daughters at home.

21 One of them is going to be 13 on April 28th and right in

22 that wheelhouse of, you know, middle school kids starting to

23 do things that they shouldn't do.

24 Lastly, kind of again completely random and off

25 topic of most things that we've talked about, prehospital

84 1 EMS physicians. I understand that, you know, whether

2 they're EMS or paramedic companies or what have you, they

3 have their doctors onboard. I understand that they are

4 still required to have CPR requirements for them even though

5 trauma or ER docs are no longer.

6 Is that something that you would consider on a

7 regulatory change to try to provide that relief for that

8 very small group of doctors?

9 SECRETARY RACHEL LEVINE: So we would be glad to

10 discuss that --

11 REPRESENTATIVE SCHWEYER: Okay.

12 SECRETARY RACHEL LEVINE: -- in terms of some of

13 the Federal requirements. We'd be glad to have that

14 discussion.

15 REPRESENTATIVE SCHWEYER: Okay. Very good.

16 Thank you.

17 SECRETARY RACHEL LEVINE: Sure.

18 REPRESENTATIVE SCHWEYER: Thank you, Mr.

19 Chairman.

20 REPRESENTATIVE DUNBAR: Thank you,

21 Representative.

22 Next will be Representative Owlett.

23 REPRESENTATIVE OWLETT: Over on this side.

24 Thank you, Mr. Chairman.

25 I have a couple questions on the program measures

85 1 as well. This is only my third budget. The biggest budget

2 I ever did before this was Owlett Custom Builder, which this

3 is a lot more complicated.

4 I had a couple questions. Looking at the

5 increases year over year from '17-'18 to '18-'19 was $33

6 million, almost 34. And this is for our Single County

7 Authorities. It says we served 560 less people. You had

8 talked about this. Part of this was the medical or the MA

9 expansion. Did everybody receive treatment that was seeking

10 it even in our rural counties? I understand this is the

11 uninsured, right?

12 SECRETARY JENNIFER SMITH: Yes.

13 So our funding goes to both the uninsured as well

14 as the underinsured. And what we mean by underinsured would

15 be individuals perhaps who have private insurance but have

16 extremely high co-pays and deductibles.

17 So one of the benefits of being in a state like

18 Pennsylvania, even though our overdose death rate is

19 exceptionally high and, you know, our per capita rate of

20 individuals with addiction is very, very high, because of

21 Medicaid expansion, that has enabled a lot of the dollars

22 coming to us from the special Federal grants around opioids

23 to be repurposed for things other than just treatment.

24 So, you know, we have --

25 REPRESENTATIVE OWLETT: So that's the 33 million

86 1 that you're talking about?

2 SECRETARY JENNIFER SMITH: So over the course of

3 the last two and a half years, we've gotten a total of $230

4 million coming to the State. And a percentage of that has

5 gone directly to our Single County Authorities. Funding has

6 more than doubled going to them.

7 So in terms of, you know, what that looks like

8 year after year, it's a little bit difficult to parse out

9 because the Federal -- the special Federal Grant funding

10 that's coming to us does not coincide with the State fiscal

11 year. And so there's some overlap in terms of one year it

12 looks like we got a whole lot of money and the next year we

13 didn't get as much. But it's just because of the way that

14 those grant periods run.

15 So we can get you some more detail about what

16 that timeline looks like, how much they got each year, and

17 what was the source of that funding.

18 REPRESENTATIVE OWLETT: Okay.

19 SECRETARY JENNIFER SMITH: There's also out on

20 our website you can click county by county and see the

21 funding streams that those counties have received over the

22 last year or so. And it breaks it down by Federal block

23 grant dollars and then what we call STR and SOR, which were

24 two different and distinct Federal Grant awardees coming to

25 our State.

87 1 REPRESENTATIVE OWLETT: Okay. So I'm not crazy

2 here. We served 560 less people and spent $34 million more

3 and then next year we're going to serve 280 people more and

4 spend $50 million more? Is that -- like, help me understand

5 that.

6 DEPUTY SECRETARY ELLEN DiDOMENICO: Sure.

7 It's a combination of a variety of things that

8 isn't just treatment. So when we think about how we're

9 appropriately spending the Federal dollars to have the most

10 robust and quality treatment system that we can, we are

11 definitely putting dollars out there that go right to

12 treatment costs. But we're also doing work that is related

13 to improving the quality of treatment. And so those numbers

14 don't exactly equate to a per-person number because they are

15 very different projects.

16 REPRESENTATIVE OWLETT: Right.

17 DEPUTY SECRETARY ELLEN DiDOMENICO: So the

18 numbers that you're seeing are the exact numbers of

19 individuals for whom treatment was paid for. But we are

20 doing far more services -- we spoke earlier about the

21 particular applications that we received in the last week to

22 fund what we would call recovery support services.

23 Those are services that are not provided by

24 licensed treatment providers and are not within the

25 treatment realm but we believe are critical services to

88 1 ensure people succeed in their recovery. So these are Case

2 Management services. These are connections to housing.

3 These are connections to things like employment

4 opportunities. These might even be services that support

5 the family members in a broader array. All of those things

6 that we know are a part of getting to a better outcome for

7 each individual who is beginning their path towards

8 recovery.

9 And so the numbers in those one line items look

10 very, very different than sort of the bigger picture that's

11 really expressed in that.

12 REPRESENTATIVE OWLETT: Okay.

13 DEPUTY SECRETARY ELLEN DiDOMENICO: Does that

14 help?

15 REPRESENTATIVE OWLETT: It helps some. I think I

16 just want to make sure that we are continuing to serve those

17 that need to be served.

18 DEPUTY SECRETARY ELLEN DiDOMENICO: Absolutely.

19 REPRESENTATIVE OWLETT: And if it's for

20 underinsured or non-insured folks, I just want to make sure

21 that folks out there know that there are services there.

22 According to this, there's a lot of money that could be put

23 toward this.

24 DEPUTY SECRETARY ELLEN DiDOMENICO: Yes.

25 REPRESENTATIVE OWLETT: I know we have a great

89 1 relationship with our coroner in Bradford County. And he

2 e-mails us every time we have a drug-related death. And

3 it's heartbreaking every time I read that report. So the

4 need is there.

5 DEPUTY SECRETARY ELLEN DiDOMENICO: Yes.

6 REPRESENTATIVE OWLETT: And I just want people to

7 know that hopefully we're utilizing this money well because

8 it's a lot of money. I mean, we're talking $50 million.

9 You know, that's a lot of money.

10 DEPUTY SECRETARY ELLEN DiDOMENICO: I'd make two

11 additional points just in terms of trying to paint that

12 entire picture.

13 REPRESENTATIVE OWLETT: Sure.

14 DEPUTY SECRETARY ELLEN DiDOMENICO: One is that

15 we have told all of our Single County Authorities that

16 should they hit a point at any point in the year where they

17 do not have sufficient dollars to provide for anyone walking

18 in the door for treatment to please let us know because we

19 have some ability to move dollars around. And so we do do

20 that. A couple of times a year we shift dollars because it

21 may be specific funding streams to fund certain services

22 that someone needs in one county but not in another. So

23 that's one piece of it.

24 REPRESENTATIVE OWLETT: Okay.

25 DEPUTY SECRETARY ELLEN DiDOMENICO: We also

90 1 really kind of think about this in this really, really

2 bigger picture and say that there are a lot of support

3 services that might be needed that are not just a part of

4 those treatment dollars.

5 REPRESENTATIVE OWLETT: Great.

6 I would appreciate that. You said something

7 about reaching out and giving us the county by county

8 breakdown. I would really appreciate that.

9 DEPUTY SECRETARY ELLEN DiDOMENICO: Yes. We'll

10 send you another document that we just recently developed

11 for Pennsylvania. It's only about three or four pages long

12 and it outlines how exactly we're spending the Federal

13 dollars and has some nice high-level outcomes. We'll make

14 sure we send that around to you as well.

15 REPRESENTATIVE OWLETT: Thank you.

16 DEPUTY SECRETARY ELLEN DiDOMENICO: Sure.

17 REPRESENTATIVE OWLETT: Thank you, Mr. Chairman.

18 REPRESENTATIVE DUNBAR: Thank you,

19 Representative.

20 Next will be Representative Gainey.

21 REPRESENTATIVE GAINEY: Hello.

22 Thank you for everything you do. You know, when

23 we talked about the opioids and everything, you've been a

24 winner, a champion. Before I say anything, I just want to

25 congratulate you on the great work that you've done.

91 1 On this Gun Task Force that we talk about that

2 the Governor is creating, my question is, you know, we've

3 had a lot of children have to deal with the after-effects of

4 gun violence, whether that's street shootings or school

5 shootings.

6 In this Task Force is there going to be any

7 component that talks about dealing with our children in

8 regards to the psychological damage that is done because of

9 gun violence, whether that's losing a loved one or being

10 affiliated with it because it happened in a setting in which

11 they were there? What will be done to make sure -- because

12 we know if not, they grow up with different triggers that

13 alert them to a couple things, one, PTSD, others become

14 copycats and, third, wanting revenge.

15 Is there anything that's going to deal with

16 family members that are impacted by the gun violence as a

17 way of reducing the amount of gun violence we have in our

18 community?

19 SECRETARY RACHEL LEVINE: Sure.

20 The Council will be releasing their final report

21 soon and I think that that will be a very important part.

22 It gets to what we, in the public health world, call ACEs,

23 or Adverse Childhood Experiences. And so that would be --

24 obviously witnessing gun violence would be a horrible

25 adverse childhood experience, which can have lifelong

92 1 consequences both for kids' mental health as well as their

2 physical health. And there really needs to be mental health

3 services and other support services for those children and

4 those families.

5 REPRESENTATIVE GAINEY: And in regards to the

6 decrease we've seen in opioid death, I just wanted to know,

7 is there -- what do you think is the difference? What's

8 made the difference? If you had to say, well, I know

9 there's not -- we all know there's not a magic wand or a

10 magic pill, but what I'm saying is that, what have we

11 invested in that you could see the rate of return has been

12 able to reduce the amount of overdose deaths that we've seen

13 when we were spiking a couple years ago?

14 SECRETARY RACHEL LEVINE: We'll both say

15 something.

16 REPRESENTATIVE GAINEY: And one more in case I

17 don't get it in. When it comes to the deaths of, you know,

18 African-Americans, the babies, are there any organizations

19 that you're working with in the city of Pittsburgh? Are you

20 dealing with a Head Start or New Voices? Is there anybody

21 that's dealing with a lot of these moms that can really be a

22 benefit to reducing the amount? Just curious about that.

23 SECRETARY JENNIFER SMITH: So I'll really quickly

24 answer the question about opioid overdose deaths. And I'm

25 going to kind of boil it down to a really simple concept.

93 1 I think it's collaboration and reduction of

2 stigma. I think it all boils down to that. When all of

3 these entities at local, state, and Federal levels, private,

4 public, work together and look towards their own solutions

5 that are most appropriate, I think that's the reason that

6 we've seen a decline in overdose deaths. I don't think it's

7 one particular program.

8 With a state that's so geographically diverse and

9 ethnically diverse, there isn't one answer that's going to

10 do it. I think it's the fact that we're all working

11 together and that it's impacted so many families across the

12 Commonwealth that we're finally understanding it as the

13 disease that it is and looking to work together to come to

14 solutions.

15 REPRESENTATIVE GAINEY: So you believe that

16 removing the stigma opens hearts to deal with and to ask for

17 more help, get the help that they need, so a lot of it has

18 to do around the stigma that was attached to them to the

19 reason why they suffered instead of asking for help? That's

20 your belief?

21 SECRETARY JENNIFER SMITH: I do believe that,

22 yes, and around softening the hearts of the individuals who

23 need to provide open access to the services that are needed

24 for those suffering from addiction.

25 REPRESENTATIVE GAINEY: Sure.

94 1 SECRETARY RACHEL LEVINE: My perspective I think

2 is on terms -- from my viewpoint is in terms of the Command

3 Center. I think that the Disaster Declarations from the

4 Governor and the Command Center has really been a game

5 changer. We have 17 different agencies all working

6 together. We have tremendous prevention activities,

7 DDAP-led prevention activities in the community, our work in

8 terms of decreasing opioid prescriptions, opioid stewardship

9 programs. We have robust rescue efforts in terms of

10 distribution of Naloxone, both to first responders and the

11 public. And then an expansion of treatment, particularly

12 evidence-based medication-assisted treatment, throughout the

13 State as we were alluding to.

14 And I think if you put that all together in our

15 local collaboration with the robust Federal funding, all of

16 that together has led to the success.

17 REPRESENTATIVE GAINEY: And in regards to black

18 infant mortality, I just want to know if you're working with

19 any organizations that deal with that targeted population in

20 the southwest, mainly the city the Pittsburgh, but Allegheny

21 County.

22 SECRETARY JENNIFER SMITH: Yes. I'll highlight

23 three organizations and then some other work that we're

24 doing.

25 REPRESENTATIVE GAINEY: Okay.

95 1 SECRETARY JENNIFER SMITH: So we work. We've met

2 with New Voices here in Harrisburg many weeks back to talk

3 about this work. We work closely with the Jewish Health

4 Care Foundation and, of course, Magee.

5 I do want to highlight that we have taken some of

6 our Maternal Health Block Grant dollars to pay for implicit

7 bias training providers who work in the space of maternal

8 health. We recognize that it's an important piece for the

9 people who are providing this care to understand what

10 implicit biases they might have and then reflect that in the

11 care that they're providing.

12 REPRESENTATIVE GAINEY: The time is going to be

13 up. I just got one more.

14 I really want to stress and we really need to

15 talk with New Voices and Head Start in regards because I

16 know that they target dealing with African-American women

17 with babies. And there's nothing like that cultural

18 confidence piece that really comes from, not through,

19 education that can really help these moms to deal with some

20 of the struggles that they may be going through to reduce

21 what we want to see the reduction in.

22 Thank you.

23 REPRESENTATIVE DUNBAR: Thank you,

24 Representative.

25 Next will be Representative Gabler.

96 1 REPRESENTATIVE GABLER: Thank you, Mr. Chairman.

2 Up here, Secretary. Thank you.

3 I have a question for the Department of Health.

4 And I want to preface this by saying that I think that one

5 of our responsibilities in this budget process is to look at

6 the limited resources we have, figure out how we can do the

7 most good, and make sure that we are respecting the

8 taxpayers in the process.

9 And so I wanted to ask a question about a pilot

10 program that recently came to my attention. The Department

11 of Health recently approved a pilot program under which a

12 tobacco cessation provider provides Chantix to Medicaid

13 recipients. However, these products are already covered for

14 Medicaid recipients and the cost is included in the

15 Healthchoices capitated rate, which, of course, is a line

16 item in the Department of Human Services budget.

17 And just for the benefit of those watching, of

18 course, the capitated rates under Healthchoices means that

19 we, as a State, pay an outside entity to essentially take

20 financial responsibility for the health care of a given

21 population . And then that's taken care of by budgeting for

22 that in that way.

23 So the concern that I have is why would we

24 approve a program under the Department of Health where

25 Chantix would be provided to the same population that we're

97 1 already paying a capitated rate for under the Department of

2 Human Services? Are we not talking between departments in

3 the way we need to to make sure that we're not duplicating

4 the same service twice on behalf of the taxpayer?

5 SECRETARY RACHEL LEVINE: So we do absolutely

6 collaborate with the Department of Human Services. I'm not

7 familiar specifically with this program off the top of my

8 head. I'd be pleased to talk with our staff and find out

9 the details about the program and all the information and

10 then we will meet with your office to discuss it.

11 REPRESENTATIVE GABLER: I would appreciate that.

12 I think that's something that we definitely need

13 to drill down into. I think there's certainly a concern.

14 And certainly we've got a large state, many departments,

15 many bureaucracies, but certainly if the right hand doesn't

16 know what the left hand is doing, that can create concern.

17 And certainly on behalf of the taxpayer, we've got to make

18 sure that we're not paying for the same service twice.

19 And so I'd appreciate a followup on that.

20 That's all the questions I have.

21 SECRETARY LEVINE: Thank you.

22 REPRESENTATIVE GABLER: I appreciate it.

23 Thank you.

24 REPRESENTATIVE DUNBAR: Thank you,

25 Representative.

98 1 Next will be the Minority Chairman of the Health

2 Committee, Chairman Frankel.

3 REPRESENTATIVE FRANKEL: Thank you, Mr. Chairman.

4 And thank you, Secretaries, for being here and

5 for the great work you do. I join my colleagues in

6 gratitude for all you do for our Commonwealth.

7 I wanted to go back to a couple of things with

8 respect to the opioid crisis. And one of them is, I think

9 -- and I talked about this last year. And I think one of

10 you addressed the issue of medication-assisted treatment and

11 that it's basically kind of a way characterized by one of

12 you -- I don't know if it was like a three- or four-month

13 type of treatment. I think for many people it is a much

14 more long-term type of treatment and in some cases a

15 lifetime treatment that I think we need to remove the stigma

16 from.

17 And also I think, you know, back away from -- I

18 think some of the stigma is also being placed onto providers

19 who are getting out of the business. So that's a very

20 difficult time sometimes for somebody who is trying to

21 recover, to find a provider who is willing to prescribe. I

22 don't know what we're doing about that. So that's one

23 issue.

24 The other issue, you know, Naloxone availability

25 has been a game changer and obviously, you know, leads to

99 1 people who go to medication-assisted treatment. One of the

2 things that we're seeing -- and there's an article that my

3 colleague Representative Innamorato sent to me earlier, an

4 article in the Post-Gazette earlier this year, about the

5 lack of State funding and how shortages, I guess, spotty in

6 some regions, but particularly in Western Pennsylvania,

7 shortage availability of Naloxone and also the inability of

8 any pharmacist being able to make any money off of this as

9 well.

10 And I was struck by -- I think one of the things

11 he said in it -- if I got this right and I don't know who

12 said it -- they said that there were 17,000 Naloxone

13 prescriptions out there and 150,000 folks utilizing it or

14 accessing it. That doesn't make sense -- or in recovery, I

15 mean people in recovery. So those numbers kind of jump out

16 at me when you blend it into this issue of Naloxone

17 availability.

18 SECRETARY JENNIFER SMITH: Yes.

19 REPRESENTATIVE FRANKEL: Since time is limited, I

20 also wanted to ask Secretary Levine to answer one other

21 thing that we both have been engaged in. And that's the

22 issue, an update, I think, on vaccinations across the State.

23 You know, we've both been trying to amend the very, very,

24 very lax standard for exempting a child from vaccinations

25 for philosophical or religious exemption, just signing a

100 1 piece of paper. We want to put, you know, some information

2 behind that and require people to discuss the exemptions and

3 the consequences of exemptions with their health care

4 providers, a simple adjustment to that, a current very lax

5 exemption.

6 So just given a very short period of time, I

7 thought I'd put emphasis on that. Let's start with the

8 Naloxone issue and the medical assisted treatment.

9 SECRETARY JENNIFER SMITH: Sounds good. And I'll

10 be super quick.

11 So the numbers that I was giving you were quoted

12 from the Medical Assistance Program only. And the Naloxone

13 numbers were for prescriptions filled through the Medical

14 Assistance Program. So that does not indicate how many

15 doses of Naloxone we as a State have distributed across the

16 Commonwealth.

17 For a couple of years, Governor Wolf had about

18 $1.5 million in his budget of State funds that specifically

19 went towards dedicated free Naloxone for the public. You

20 will not see that line item in this budget. And that's

21 because of receiving so much Federal funding. We are

22 utilizing the Federal funding to fund those Naloxone

23 efforts. And so we have about $5.4 million dedicated

24 specifically to Naloxone distribution in the communities.

25 REPRESENTATIVE FRANKEL: Okay.

101 1 SECRETARY JENNIFER SMITH: And that distribution

2 happens in a number of different ways. So there are some

3 free Naloxone giveaways that we coordinate through the

4 Department of Health and their Health Centers. We have what

5 we call centralized coordinating entities in every county

6 that are responsible for making requests to the State

7 through PCCD for Naloxone, so that's a second mechanism.

8 And then there are ways that our Department directly funds

9 some specific Naloxone asks from different communities.

10 So I can get you some more information on

11 specifically where the Naloxone has been going, which

12 counties it's going to, how much has gone there, if you're

13 interested in that kind of data.

14 REPRESENTATIVE FRANKEL: And you would state that

15 there is no unmet need at this point for that?

16 SECRETARY RACHEL LEVINE: That is correct. There

17 is no unmet need. We talked with Prevention Point in

18 Pittsburgh where that article came from and we resolved

19 their issues.

20 SECRETARY JENNIFER SMITH: Yes. I think the

21 challenge is more in terms of the version of Naloxone that

22 they would like to have is different from the kind of

23 Naloxone that we are able to give through the standing

24 order. If you'd like more information, we can share that.

25 Very quickly on that medication-assisted

102 1 treatment front, I would love for us to be able to stop

2 having a debate between whether it's medication-assisted

3 treatment or drug-free treatment. In my world, treatment is

4 treatment. And if you're a treatment facility, you should

5 be able to offer whatever treatment is clinically

6 appropriate for the individuals that walk in your doors.

7 Sometimes that means offering them medication and sometimes

8 it doesn't. It depends on the individual.

9 I really hope that we get to a place in the State

10 where we don't have to talk about, well, does this person or

11 does this facility offer medication or doesn't offer

12 medication? Every facility that offers good treatment

13 should have the capability of providing whatever the

14 individual needs that walks through their door.

15 I appreciate you asking that question and your

16 support of that method of treatment.

17 SECRETARY RACHEL LEVINE: So I'm going to briefly

18 do all three.

19 One is that we have really worked to have the

20 Naloxone available to the public as well as to all First

21 Responders through the mechanisms that Secretary Smith was

22 saying. They actually have handed out almost 14,000 kits of

23 Naloxone through the community health centers, our community

24 health centers in Pittsburgh and Philly, etc. In addition

25 to the standing order through pharmacies, in addition to the

103 1 Naloxone that's been given to EMS, since 2016, law

2 enforcement has 7,000 reversals. In the last number of

3 years, EMS has administered 32,000 doses of Naloxone. So

4 there is no shortage. We'll make sure that anybody who

5 needs Naloxone has Naloxone.

6 I would agree 100 percent in terms of

7 medication-assisted treatment and its availability. We have

8 worked through the Centers of Excellence, the PacMAT

9 Programs, and many other programs to expand access to

10 Buprenorphine medications.

11 We also worked with the medical schools that by

12 the end of this year every graduating medical student in

13 Pennsylvania will have gotten the training necessary for

14 their waiver for Buprenorphine so that it's really

15 incorporated into medical practice.

16 And then finally in terms of immunizations, you

17 know, I think that we have made progress by changing the

18 provisional period with schools by which immunizations had

19 to be up to date. So we are above the herd immunity level

20 but we still have too many kids that don't have their

21 immunizations and we have pockets of kids where they are

22 under-immunized, which puts us at risk for local outbreaks

23 of measles and other.

24 So we'd love to work with you in terms of

25 legislation to try to improve our immunization rights in any

104 1 way possible.

2 REPRESENTATIVE FRANKEL: Thank you.

3 REPRESENTATIVE DUNBAR: Thank you,

4 Representative.

5 Next will be Representative Heffley.

6 REPRESENTATIVE HEFFLEY: Thank you, Mr. Chairman.

7 I just want to say kudos on getting the Naloxone

8 out there readily available. I had a young man in my office

9 the other week who was saved by Naloxone and is now living

10 in recovery. I think it's a wonderful program.

11 A question that I have -- and I just want to

12 commend the Administration of Washington, D.C., for

13 continuing to provide us with increases in funding. It's

14 much needed on this front.

15 DDAP has implemented a voluntary resource for

16 substance use professionals to communicate the availability

17 of beds in treatment. Yet I still hear from our local SCAs

18 and from folks that are looking for treatment that they have

19 to wait. So if they want to get in treatment, they would

20 try to develop Warm Handoff Programs but yet we can't find

21 available beds. We can't find the treatment that they need.

22 And, unfortunately, there have been deaths related to the

23 fact that people are waiting to get into treatment.

24 With that said, we have a bill that had passed

25 the House unanimously regarding bed registry. Currently

105 1 there is a -- PEMA has a bed registry that is used for

2 emergency services. It's also used for long-term care.

3 Also there's programs that are available through the PDMP to

4 provide that type of information.

5 What we're hearing is twofold. One is that in

6 rural counties like Carbon County, we have no outpatient

7 providers other than our SCA doing the best they can, but we

8 have no outpatient providers. We have no inpatient. So

9 people are having to travel an hour to get treatment.

10 So the question is twofold. What can we do to

11 better utilize the programs that we have right now in PEMA?

12 And we've had meetings with your staff in regards to that.

13 And if you would send a letter because the Federal

14 Government seems to be very supportive in wanting to combat

15 the opioid epidemic. Could we find out from the Federal

16 Government whether we could utilize that program to enhance

17 a better bed registry to get people that need treatment into

18 treatment right away since the need is there and people are

19 dying while they wait for treatment?

20 And secondly, how can we better -- what can you

21 do from the Department to better serve the rural counties

22 where we have no outpatient providers to come in? So these

23 are my two questions.

24 SECRETARY JENNIFER SMITH: Thank you,

25 Representative.

106 1 And I want to say that I appreciate your tireless

2 efforts in this space. Truly an advocate. I really

3 appreciate that you're willing to work with the

4 Administration in terms of crafting legislation that you

5 think will be very helpful to people.

6 So I want to address the question in sort of a

7 slightly different manner, which is to really get at the

8 bigger issue of capacity. So bed registries are a nice

9 thing to have where there's an abundance of capacity and

10 folks are just looking to locate where that capacity exists.

11 I think from our perspective the bigger issue is

12 that folks are on wait lists because there aren't

13 necessarily providers in their area that are offering

14 services for the type of insurance that they have.

15 So the really big issue in Pennsylvania is that

16 we've got providers who for financial reasons have capped

17 the number of individuals that they are willing to accept

18 who are publicly funded, whether that's Medical Assistance

19 or whether that's funded through our Block Grant dollars.

20 And so some of the things that we're needing to

21 work on is making sure that we're providing adequate

22 reimbursement rates for those providers so that they can

23 begin either raising or lifting altogether the caps that

24 they have for individuals seeking treatment who are publicly

25 funded clients. And so, you know, the need for a bed

107 1 registry sort of runs even deeper than just locating where

2 facilities are. I think that's the easy part. The hard

3 part is locating and building capacity for the individuals

4 based on the funding source that they're utilizing and

5 making sure that it's in close proximity to where they live.

6 REPRESENTATIVE HEFFLEY: And I would say that

7 having a bed registry that would complement that and from

8 what I had seen of the bed registry that PEMA already has,

9 there are categories where we could list what type of

10 insurance would be acceptable to those facilities.

11 I think we also direly need it for mental health.

12 I mean, there's so many people that have a dual diagnosis

13 and people are sitting in emergency rooms sometimes seven to

14 ten days in an ER getting no treatment at all and driving up

15 the cost of everything because they don't have a way to find

16 those beds.

17 So I look forward to continuing to work with you.

18 I know it's been frustrating. I know the bill is over in

19 the House. I would really like to see that letter to the

20 Federal Government asking if we could expand upon PEMA.

21 But I just want to mention the other crisis that

22 I'm hearing from my -- from our providers is meth. And I

23 just feel that right now as a State or as a Commonwealth,

24 you know, we're very unprepared to deal with that crisis

25 just as we were unprepared to deal with the heroin crisis.

108 1 And it's really going to kind of ramp up here and become a

2 huge health issue.

3 Thank you.

4 REPRESENTATIVE DUNBAR: Thank you,

5 Representative.

6 Next will be Representative Flynn.

7 REPRESENTATIVE FLYNN: Thank you, Mr. Chairman.

8 My question is for Secretary Levine. I was

9 wondering what is the timeline for the Department to release

10 the new hospital regulations for public comment?

11 SECRETARY RACHEL LEVINE: So thank you for that

12 question. As I pointed out, the last time the hospital

13 regulations were released was in 1984. Things have changed

14 a lot since 1984. We have been working on those regulations

15 over the last number of years. The Governor's Office has

16 asked us to split it into packages as opposed to one

17 enormous regulation. We have done that.

18 An update in terms of the timeline of the first

19 packet?

20 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: Yes.

21 We're working on a timeline to promulgate all six

22 groupings before the end of this Administration. So Group 1

23 has gone back and forth from the Department to the

24 Governor's Office and back. And so those packages will roll

25 out one after the other until the entire package is

109 1 promulgated and then all of the dates will line up to

2 effectuate the change.

3 SECRETARY RACHEL LEVINE: So we're looking to get

4 it all done by the end of our term.

5 REPRESENTATIVE FLYNN: I've heard numerous

6 concerns from anesthesiologists in my district and they're

7 very concerned about, you know, potential changes in the

8 laws. Is the Department aware of their concerns and, if so,

9 what steps are you guys taking to address them?

10 SECRETARY RACHEL LEVINE: Sure.

11 And one of the packets will address the issues in

12 terms of anesthesiologists and CRNAs. We are well aware of

13 the different issues involved. We have met both with the

14 anesthesiologists. We have met with the CRNAs. And we'll

15 be working to try to craft and thread the needle in terms of

16 the right policy in terms of that. And that will be in the

17 regulations. It's not in the first packet. It will be

18 later on. So we have met with the anesthesiologists and we

19 have met with the CRNAs as well.

20 REPRESENTATIVE FLYNN: Thank you.

21 REPRESENTATIVE DUNBAR: Thank you,

22 Representative.

23 Next will be Representative Warner.

24 REPRESENTATIVE WARNER: Thank you, Mr. Chairman.

25 Secretaries, thank you very much for being here

110 1 with us today. And I also thank you for your patience in

2 this very long hearing.

3 I want to discuss something that hasn't been

4 talked about today. We talked a lot about the opioid

5 epidemic and rightfully so. That is a major issue in our

6 State. But another issue that I see that is very dire is

7 our EMS services. Right. It just so happened to be that

8 this morning before the hearing I saw in a newspaper article

9 from the Morning Call that the State's EMS is stretched so

10 thin in Pennsylvania that in some places ambulance calls go

11 unanswered.

12 I can tell you firsthand in the municipality that

13 I live in, which is about 30 miles south of Pittsburgh, that

14 it is not uncommon for a 30-minute wait time for an

15 ambulance. I've experienced this firsthand waiting for an

16 ambulance for my son.

17 Again, I'm not trying to push aside any of the

18 other things that we discussed today, but if we can't get

19 people to a hospital or get to them in time, everything else

20 that we've discussed kind of seems pointless.

21 So the question is, what is the Department doing

22 to stem the rapid decline of EMS coverage in the

23 Commonwealth?

24 SECRETARY RACHEL LEVINE: Thank you for that

25 question. I saw the same article.

111 1 So there are a number of different issues.

2 That's kind of the perfect storm of different issues. There

3 are absolutely rural staffing shortages. Now, despite an

4 increase in the number of new EMTs that are being certified

5 each year, certain parts of the Commonwealth, especially in

6 rural areas, have been affected by a shortage of EMS

7 providers, which is impacting care, as you had talked about.

8 We are pleased to work with the Legislature. I

9 know there's been a number of different bills, House Bill

10 1869, that would allow the Department greater flexibility in

11 terms of addressing workforce shortages. And House Bill

12 1838, which would increase the EMS operating fund, would

13 create more resources for the Department to be able to

14 address that. So there are a number of different ways that

15 we would like to do that. And we're pleased to work with

16 the Legislature. It is absolutely an issue in terms of

17 reimbursement to EMS and the ability to keep them open and

18 staffed in rural areas.

19 So there's a lot of different things that we can

20 do. A lot of it's not something that we can just do in the

21 Department, but we're pleased to work with you in the

22 Legislature.

23 REPRESENTATIVE WARNER: Yes. Thank you.

24 I also know that one of their concerns is -- and

25 I don't mean to get into a debate on this -- but they do

112 1 have a concern about a $15 hour minimum wage putting them

2 out of business, especially in the rural areas with a lower

3 cost of living. I just want to mention that.

4 I want to get to one other thing real quickly

5 while I have time. Another thing, it's what I consider a

6 health epidemic, what I consider a silent epidemic only

7 because the people that have this disease appear healthy to

8 everybody, and that is the overwhelming increase of food

9 allergies in our society.

10 Since 2000, food allergies have increased over 50

11 percent in children. There's roughly an average of two

12 children in every classroom with food allergies. And

13 currently a food allergy sends someone to the emergency room

14 every three minutes in the United States.

15 With that being said, again, the same question,

16 what is the Department of Health doing? Is there anything

17 proactive, anything that you guys are looking at to help

18 stem the epidemic of food allergies in the Commonwealth?

19 SECRETARY RACHEL LEVINE: So I'm not really

20 prepared to be able to answer that question today. But

21 we're pleased to talk with our staff and to look further

22 into that and then we're pleased to meet with your office to

23 discuss what the Department can do.

24 Again, I'm a pediatrician so I am aware of food

25 allergies in children. There are a number of different

113 1 manifestations of that. But the most severe can be an

2 anaphylactic response requiring epinephrine and EMS, etc.,

3 so we're pleased to investigate what the Department could do

4 to help and then we'll meet with your office.

5 REPRESENTATIVE WARNER: Yeah. Thank you.

6 I would definitely appreciate the Department

7 taking a further look at it. I just wanted to note in 2018

8 we passed Act 93, which expanded the use of epinephrine auto

9 injectors throughout the Commonwealth. It pretty much gave

10 authority to anybody to be able to get a prescription for

11 it.

12 SECRETARY RACHEL LEVINE: Thank you.

13 REPRESENTATIVE WARNER: But I do have a concern

14 that on the Department's -- on your website, you have a

15 website, you have a listing there, life-threatening

16 allergies, and it apparently has not been updated for some

17 time. And there are some bills mentioned from 2010, 2012,

18 where we had given bus drivers and schools different

19 authorities for epinephrine auto injectors. But Act 93 that

20 pretty much allows anyone in the Commonwealth of

21 Pennsylvania to acquire one is not mentioned there .

22 And again, I'm just advocating on behalf of those

23 with food allergies. It is what I call a quiet epidemic.

24 And I would also like the Department of Health to take a

25 closer, more serious look at it.

114 1 SECRETARY RACHEL LEVINE: Absolutely.

2 REPRESENTATIVE WARNER: Thank you.

3 SECRETARY RACHEL LEVINE: Thank you.

4 And we'll fix our website.

5 REPRESENTATIVE WARNER: Thank you.

6 REPRESENTATIVE DUNBAR: Thank you,

7 Representative.

8 Next will be the Chairman of the Human Services

9 Committee, Chairman Murt.

10 CHAIRMAN MURT: Thank you, Mr. Chairman.

11 I have a question. But before I ask the

12 question, I just want to talk about stigma for a little bit.

13 I thank you for bringing that up. Stigma for these issues

14 is as deadly as the disease of addiction. And I like to say

15 the disease of addictions because it is a disease and the

16 states that treat addictions as a disease have been the most

17 successful in this struggle. So I think it's important that

18 we, as I said, treat it as a disease and not as a character

19 flaw or a human failing or anything like that. It truly is

20 a disease.

21 One of the things that will help this is mental

22 health and addiction parity. There is the law of the land.

23 Yet the way that it plays out in the Commonwealth and many

24 other states is not so pretty. It's ugly as a matter of

25 fact. And promising somebody two or three visits with a

115 1 therapist or a psychologist and once in a while to a

2 psychiatrist to get the right balance in the mix of

3 medications and face-to-face therapy and so forth is a great

4 thing, but you shouldn't feel grateful if somebody says,

5 well, if you need three more visits or five more visits, you

6 just fill out all those forms and you're going to be fine.

7 Doesn't work like that.

8 We're working on mental health parity in the

9 Insurance Committee right now. House Bill 1696 should be

10 kicked out in March and we have plenty of time to get it

11 through the House and the Senate. This is a very, very

12 important bill. We've worked with all the stakeholders on

13 this. And this is going to go a long way in helping the

14 Commonwealth of Pennsylvania finally achieve some measure of

15 mental health parity.

16 My real question has to do with our veterans.

17 Our Commonwealth is home to thousands of men and women who

18 have served in the armed forces, myself included. I served

19 in Iraq for 14 months in combat. We're one of the top

20 states in the veterans population.

21 Sadly, statistics tell us that almost every hour,

22 the statistics tell us 22 veterans a day take their lives.

23 And I think that's low. I think it's higher than that, to

24 be very honest with you.

25 And I would like to know, Secretary, if you don't

116 1 mind, what outreach and what kind of coordination is being

2 done to assist veterans, not just with substance abuse

3 disorders but also posttraumatic stress and suicide?

4 Thank you.

5 SECRETARY JENNIFER SMITH: Yes.

6 Thank you for that question. Something that

7 we've talked a little bit about together in our meetings.

8 So we share that same passion and concern around veterans.

9 And first and foremost, thank you for your service, sir, to

10 the nation.

11 So in terms of some of the specific collaboration

12 that we've had with the Department of Military and Veterans

13 Affairs, in late summer, early fall of 2019, DMVA launched

14 an educational media campaign that was geared specifically

15 towards veterans. And that campaign utilized $500,000 of

16 our grant funding, which is tied to opioids specifically.

17 And that campaign used radio, TV, and digital advertisements

18 to highlight some of the unique challenges that veterans

19 face. So personalizing those messages to them, encouraging

20 them to reach out for help and providing what those

21 resources look like in terms of help.

22 I can tell you that in Fiscal Year '18-'19

23 through our funding sources, there was $148,000 spent on

24 veterans, which is a huge increase from the year prior. In

25 '17-'18, only $5,500 was spent on veterans'

117 1 treatment-related services.

2 Now, again, these are dollars for the under or

3 uninsured. So it's not representative of Medical Assistance

4 funding or private pay insurance funding. But just for that

5 veterans' population, that was a huge increase over that

6 year's time. And what those dollars pay for are not just

7 treatment services but also really crucial case management

8 and housing services and recovery support services.

9 So we recognize that this is a population for

10 whom those wrap-around services and the need for very

11 intense recovery supports are critical to their continued

12 recovery. I can also tell you that we have some really

13 great facilities here in Pennsylvania that specifically

14 provide programming for veterans seeking treatment.

15 The Retreat at Lancaster and Treatment Trends are

16 world-class facilities here that provide specific PTSD and

17 SUD co-occurring treatment. There's also a program called

18 Just For Today that provides excellent recovery support

19 services for veterans that we're supportive of. And then as

20 a Department, we serve on numerous Advisory Councils related

21 to veterans as well as the PA Cares Task Force and a

22 specific policy academy that was centered around veterans.

23 So we've done a lot of work in our space specific

24 to substance use disorder and how that impacts veterans.

25 CHAIRMAN MURT: I appreciate that.

118 1 And just for everyone's edification,

2 homelessness, unemployment, suicide amongst veterans is

3 significantly higher than it is for the general population.

4 I know you know that, Secretary, so thank you for your

5 support.

6 SECRETARY JENNIFER SMITH: Thank you.

7 CHAIRMAN MURT: Thank you, Mr. Chairman.

8 REPRESENTATIVE DUNBAR: Thank you, Mr. Chairman.

9 And now will be the Chairman of the Health

10 Committee, Chairman Rapp.

11 REPRESENTATIVE RAPP: Thank you, Mr. Chairman.

12 And thank you, Secretary Levine and the other

13 Secretaries, for being here.

14 Many of my questions have been answered today. I

15 think there was a lot of really good information put forth.

16 But I do have one question. Hopefully we end on a high note

17 here.

18 In the Governor's Budget, the information I have

19 was that rural health under health innovation was cut some

20 20 million to 9 million which is more than 50 percent. So

21 my question, Dr. Levine -- I'm sure you can answer this --

22 is that money, do you know, is that going to the Rural

23 Health Initiative and could you expand a little bit on the

24 funding for the Rural Health Initiative and the benefits

25 that that will bring to rural Pennsylvania and rural health

119 1 care?

2 Thank you.

3 SECRETARY RACHEL LEVINE: Sure.

4 In terms of a cut --

5 REPRESENTATIVE RAPP: I thought it was an easy

6 question.

7 SECRETARY RACHEL LEVINE: Sorry.

8 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: So the

9 primary funding for the Pennsylvania Rural Health Model

10 comes from a partnership with CMMI, the Centers for Medicare

11 and Medicaid Services. So they in total made up to $25

12 million available to the State over the course of many

13 years. So the bulk of that funding was upfront. And so the

14 appropriation allowed us to bring those dollars in.

15 The money right now is used by the Department to

16 support the in-house employees and workers who work

17 alongside the hospitals. It also pays for some of the

18 methodology work and to get those global budgets put in

19 place.

20 As this transitions out of the Department and

21 goes to the Rural Health Redesign Center, our goal is to

22 transition that relationship that CMMI has with the

23 Department of Health to that independent authority to

24 administer any of the funding that might continue to come

25 from CMMI. But really the benefit of having that authority,

120 1 that outside group, will allow it to also contract with

2 other states who might want to execute a model similar to

3 this and also receive private foundation dollars to support

4 the effort.

5 SECRETARY RACHEL LEVINE: So I just wanted to

6 thank you. I couldn't quite hear what you were saying. But

7 the Rural Health Redesign Center is in the process of being

8 set up. There are actually several different Legislative

9 members that will be added to the Board, but it will be up

10 and running, shovel ready, so to speak, by May 26th. We'll

11 have our first official board meeting, although we'll have

12 some ex-officio board meetings even beforehand.

13 The funding, as Sarah was saying, will continue

14 to have some money from CMMI, but eventually the Rural

15 Health Redesign Center will be self-funded, looking for

16 foundation grants and other types of grants as well as

17 consulting fees from working with other states.

18 REPRESENTATIVE RAPP: Thank you so much.

19 Thank you, Mr. Chairman.

20 REPRESENTATIVE DUNBAR: Thank you, Chairman.

21 Chairman Bradford, any comments?

22 MINORITY CHAIRMAN BRADFORD: No.

23 REPRESENTATIVE DUNBAR: Before we close, I did

24 have a couple questions. I had my name on the list before

25 Stan left so I'm going to ask my questions.

121 1 During the Governor's budget address -- I'm

2 paraphrasing a little bit -- one of the first things he had

3 said was that when we work together, we can do great things

4 as far as the budget is concerned. And I agree with that.

5 But then when I look at the budget, I get somewhat dismayed

6 when I see we're playing the same games with different

7 program eliminations. Diabetes, regional cancer centers,

8 Lupus, regional poison control, trauma, epilepsy, Tourette

9 Syndrome, ALS, leukemia all get zeroed out.

10 And I heard you say earlier, Dr. Levine, about

11 legislative adds. And at the same time though, anemia,

12 hemophilia, and Sickle Cell don't get eliminated. I don't

13 know why they have special preference disease categories

14 that they don't get eliminated.

15 And I don't know how something can be a

16 legislative add. It's like we're playing this game and

17 we're dancing this dance. I'm just tired of it myself.

18 My question to you is, I'm sure you do support us

19 funding these things totally?

20 SECRETARY RACHEL LEVINE: So, you know, I

21 understand your thoughts. The Governor's Budget is sort of

22 a starting point for our negotiation and our collaboration.

23 We will work with you to --

24 REPRESENTATIVE DUNBAR: And I understand that.

25 But to me, I look at it if it's a balanced -- it's a budget

122 1 that's out of balance when we start because we know these

2 are all going back in. And all I'm asking is maybe use your

3 influence with him so we don't play this dance again in

4 future years.

5 I'm sure you have more influence than I do in

6 that regard.

7 SECRETARY RACHEL LEVINE: Thank you.

8 REPRESENTATIVE DUNBAR: And, you know, these are

9 not partisan issues. I'm sure we all want these things in

10 there. I don't think any of us are opposed to this idea.

11 Can we just stop the dance?

12 SECRETARY RACHEL LEVINE: Thank you for your

13 thoughts, sir.

14 REPRESENTATIVE DUNBAR: Secondarily -- very good

15 answer.

16 SECRETARY RACHEL LEVINE: Thank you, sir.

17 REPRESENTATIVE DUNBAR: I appreciate your

18 involvement in the performance-based budgeting hearings.

19 And we spoke then about these measurements, and the idea

20 behind this was to help decision-makers in the

21 decision-making process. There was some things that I saw

22 on the Department of Health that I did want to bring up and

23 I thought it would be better to bring it up in this setting

24 as opposed to the PBB hearing.

25 And this deals strictly with the Administration,

123 1 their performance, and specifically overtime costs. If you

2 go to the hearing -- if you go to the PBB book it would be

3 page 40 if you want to reference it later. But overtime

4 costs in 2015, that year end was 424,000. Last year it's up

5 to 2.3 million, which is like a 500 percent increase.

6 There is some genuine concern there about those

7 costs and what's going on. If you break it down, in 2015

8 for every employee, it would be $373 extra by overtime. Now

9 it's $2,229. What's going on?

10 SECRETARY LEVINE: Sure. We can explain that,

11 sir.

12 EXECUTIVE DEPUTY SECRETARY SARAH BOATENG: So I

13 first want to echo your comments around performance-based

14 budgeting. This was the first year that the Department of

15 Health participated in that effort. And while it was an

16 effort, I really do think that we learned a lot from the

17 experience. And I think the report that was put out really

18 shows the return on investment in public health funding and

19 gives us some areas to look at.

20 You rightfully point out the area of overtime.

21 So the bulk of those dollars are overtime paid in our

22 Quality Assurance Deputate. So these are facility surveyors

23 who go on hospital, nursing home, complaint surveys. So we

24 have State responsibilities there. We also act as agents of

25 CMS. And so a combination of things has led to that type of

124 1 overtime.

2 So we've had a significant increase in the amount

3 of facilities that we have here in Pennsylvania, including

4 new home care agencies, home health agencies. And we've

5 also had a significant challenge in recruiting the clinical

6 people that we need to do that work.

7 So a lot of our health care colleagues face the

8 nursing shortage that we have here in Pennsylvania. We

9 simply don't have enough trained nurses here in Pennsylvania

10 to meet demand. And we see that at the Department of Health

11 as well. So we have had challenges recruiting additional

12 staff to fill those open complement slots. And yet the work

13 is still there and it's absolutely necessary work. If

14 there's a complaint, we must go there. That results in

15 overtime for some of our staff.

16 REPRESENTATIVE DUNBAR: And I don't doubt that

17 the work has to get done. I also have concerns in the fact

18 that your turnover rate is close to 19 percent. I don't

19 know why. Maybe you can help elaborate. But that is

20 certainly something that can drive overtime costs up as

21 well.

22 SECRETARY RACHEL LEVINE: That is also absolutely

23 one of the factors. So we have, you know, a system in terms

24 of payment in terms of the Civil Service rates that we pay.

25 So we have difficulties in recruiting, but we also have

125 1 difficulties in retention where we train an excellent nurse

2 in terms of Quality Assurance and then one of our excellent

3 health systems recruits that nurse and pays her much more

4 than we can possibly pay her in the Civil Service system,

5 him or her, and that leads to people leaving.

6 So we have actually worked to improve that. We

7 have worked with HR, who has worked with our QA and our

8 Deputy Secretary for Quality Assurance in terms of

9 recruitment. We actually have lots of different activities

10 to try to recruit and retain excellence nurses. And we have

11 improved our complement so we're hoping that the overtime

12 will start to go down. But it has been a challenge.

13 REPRESENTATIVE DUNBAR: Yeah. And I'm hopeful

14 that we continue to monitor this as we go forward.

15 SECRETARY RACHEL LEVINE: Absolutely.

16 REPRESENTATIVE DUNBAR: With that, we'll

17 conclude. I appreciate your endurance. And we will adjourn

18 today and we'll reconvene tomorrow morning at 10 o'clock

19 with the Department of Transportation.

20 SECRETARY RACHEL LEVINE: Thank you.

21 EXECUTIVE DEPUTY DIRECTOR SARAH BOATENG: Thank

22 you.

23 SECRETARY JENNIFER SMITH: Thank you.

24 DEPUTY SECRETARY ELLEN DiDOMENICO: Thank you.

25 REPRESENTATIVE DUNBAR: Thank you.

126 1 (Whereupon, the hearing adjourned.)

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127 1 I hereby certify that the proceedings and

2 evidence are contained fully and accurately in the notes

3 taken by me on the within proceedings and that this is a

4 correct transcript of the same.

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8 Jean M. Davis 9 Notary Public

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