The Senate Committee on Health & Human Services met on December 10 to discuss the following interim charges:

Public Health

  • Examine the emerging public health concerns from the rise in e-cigarette use and “vaping,” especially among minors. Determine if additional policies or laws are needed to protect the public’s health.
  • Monitor the implementation of Senate Bill 21, including strategies to address tobacco and nicotine use, including e-cigarettes and vaping, by adolescents.

Health Care Costs

  • Examine the current status and future direction of the following programs: The Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver, including the DSRIP Transition Plan, and the Healthy Texas Women Section 1115 Demonstration Waiver.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

Opening Statements

  • Chair Kolkhorst – Today, we will be discussing the vape/e-cigarette public health crisis and the 1115 wavier, 1115 waiver will focus more on the global impact of the waiver and DF.
  • Sen. Perry – We have some real challenges in the state due to the 1115 waiver.

Public Health Interim Charges

  • Examine the emerging public health concerns from the rise in e-cigarette use and “vaping,” especially among minors. Determine if additional policies or laws are needed to protect the public’s health.
  • Monitor the implementation of Senate Bill 21, including strategies to address tobacco and nicotine use, including e-cigarettes and vaping, by adolescents.

Public Health – Panel 1

Dr. Manda Hall, Department of State health Services

  • DSHS presentation on vaping
  • Provides an overview of vaping including information from the CDC.
  • E-cigarette use has been stable since 2015, but has dramatically increased in youth; trend of lung disease increasing due to vaping or e-cigarettes
  • 2,290 cases and 47 deaths have been reported by the CDC
  • Texas, California and Illinois are the states with the most cases reported
  • 273 possible cases of a lung disease and one has resulted in death. Most are male and under 18 years of age. Of these 90% have reported using THC.
  • DSHS has issued two health alerts that provide information to clinicians on how to report cases.
  • Prevention programs: “say what” contract with TXST where they provide
  • Peers against tobacco (UT) in 22 colleges and universities in the state.
  • Enforcement: FDA-backed
  • Ty-tap behavioral intervention program.
  • Cannabis and vitamin e acetate are
  • CDC recommends individuals do not use THC containing e-cigarette products.

Emily Blanford, National Conference of State Legislatures

  • 10 states have required a ban or ban on certain flavors. Some of these bans have been taken to court.
  • 2019 leg trends: 585 related bills and 111 actions regarding e-cigarettes and vaping.
  • Massachusetts was the first state to ban overall.
  • California has updated their cannabis labeling policy.

Questions for Panel 1

  • Sen. Kolkhorst – Who regulates these products? The FDA had a “deeming” rule. What is the role of the FDA and CDC? Are most of these products made in the US?
    • Hal- we have not received that information.
    • Sen. Kolkhorst- so we do not know where these products come from?
    • Hal- we have been working with the CDC to investigate this, but as of right now, we are not sure where they come from.
  • Sen. Kolkhorst – We do not know what is in them, there is no labeling policy, we do not know where they come from?
  • Sen. Perry – They made vaping appealing to kids and marketed it under the guise they could get people off of cigarettes. We either outlaw the whole deal or we regulate it, but we do not have the resources to do this. I do not know what the solution is, but this situation is frustrating that these companies have taken this route and that we are here today. Where does personal responsibility lie?
  • Sen. Johnson – Are you aware of federal funding streams dependent on the state meeting tobacco goals?
    • Hall – We receive funding through the FDA
  • Sen. Johnson – Asks after the Substance Abuse Block Grant
    • There is a block grant housed at HHSC, can ask HHSC for the specifics
  • Sen. Johnson – Are there gaps in funding for things that would do a better job of discouraging youth from vaping?
    • HHSC has looked at Tobacco Prevention & Control program funding as well as maternal wellness though the Title 5 grant, both have allowed us to push information; HHSC also maintains websites, info for older youths, etc.
  • Sen. Johnson – So perhaps a benefit to the state if we can block physical issues resulting from vaping
  • Sen. Johnson – Asks after contract under new prevention activities
    • Had a contract in place with UT Austin, amending to allow for additional funding which will allow UT to possibly expand
  • Sen. Johnson – This is the “Better Bad Habit” entity?
    • Yes, one of the campaigns under way
  • Sen. Campbell – Asks for specifics on the HHSC info campaign
    • Describes kits available, university partners, etc.; program is voluntary and schools sign up for the “Say What!” program
    • HHSC also holds summits
  • Sen. Campbell – How do people get to the summits? Invitations?
    • Part of the school districts and youths would participate through them
    • Youth ambassadors are part of the outreach; outreach can look different ways depending on each school’s approach
  • Sen. Kolkhorst – Big first step would be messaging on not using substances with unknown components
  • Sen. Powell – Concerned about the statistics for ISDs, outreach looks low in some areas (North Texas) and usage is high; need to have a more defined and aggressive approach, need many more resources around the state
  • Sen. Perry – Are the university programs grants from the federal gov, grants from you?
    • Funding comes from the tobacco program, state, CDC, etc.
  • Sen. Perry – Can you get me the dollars we’ve spent on corporate irresponsibility and personal irresponsibility?
    • Would need to get back to you with this
  • Sen. Perry – I need this info
  • Sen. Kolkhorst – Good question
  • Sen. Perry – Tired of picking up the tab for addictive substances and the health care costs as well; big question is are we going to let this perpetuate
  • Sen. Kolkhorst – What states have banned e-cigarettes?
    • Blanford – Massachusetts had a recent bill, but would need to get this info
  • Sen. Kolkhorst – California has a labeling law, but only for cannabis, but silent on other ingredients
    • Blanford – Yes, requires universal symbol for cannabis

Public Health – Panel 2

Dr. Phillip Huang, Dallas Health and Human Services

  • 46 patients have been admitted in Dallas for this specific lung disease.
  • These patients are young. The median age is 22. Many of these patients were previously healthy, but now they are now unable to breathe for themselves.
  • On average, they are in the hospital for seven days.
  • We have been working with the FDA, CDC, UT Public Health, media coverage, etc.
  • A large portion of those admitted to the hospital have been admitted to the ICU.
  • We do not know the long-term effects of e-cigarette use, but the studies we have done are not positive.

Earnest Hawk, UT MD Anderson

  • A lack of federal regulation has resulted in ill-defined and poorly communicated chemicals in these products.
  • Many of these products do have nicotine and are just as addictive as cigarettes and the exposure
  • Most of these products have not proven to be safe or effective.
  • Notes studies done that these products can cause cancer and mentally damage youth.
  • E-cigarettes and vaping have been proven to not be an effective way to quit cigarettes.
  • The Juul is very popular with youth due to the flavors and design. From public demand, the company has stated they will discontinue certain flavors.
  • Part of the concern is that these products are a gateway to traditional tobacco products.
  • It is important to standardize and label appropriately these products. It is important to study the effects of these products on humans and animals. Pub. Education, Taxation programs, etc. could be used to

Chair Kolkhorst – We did invite Juul, but they declined. We are surprised at the market penetration.

  • Chair Kolkhorst – it was a bold move for A&M to ban vaping and e-cigarette use.

Dr. Jay Maddock, Texas A&M University

  • Notes the increase in high school rates of smoking e-cigarettes and vaping.
  • A&M decided to go 100% smoke-free. There is a ban on all property.
  • Enforcement is harder than traditional cigarettes due to the lack of smell and other factors.
  • Need to look at increasing taxes on these products
  • Need to look into shops who are selling to minors.
  • Need to ban certain “child” flavors.
  • We need to stop the rate of high schoolers who come into college who are vaping.

Questions for Panel 2

  • Sen. Perry- where is e-acetate added?
    • Hawk – we are not sure.
  • Sen. Perry- on page 9 of your handout, but you do not recommend banning them?
    • Hawk – your recommendations stop short of doing away with the problem.
  • Sen. Perry- we have been here before. Are there any new revelations
  • Sen. K- is there any mandatory labeling?
    • Hawk – it is not regulated at this time.
  • Sen. K- vitamin e acetate is ment to be absorbed in the stomach, and the lungs cannot process this. Is that a true statement?
    • Hawk – the flavors that are put into these juices have been approved for human consumption, but not human inhalation.
  • Wang- I would like to add that kid
  • Sen. Perry- do we have any laws on the books that could hold
  • Sen. Kolkhorst- we have an assumption that anything that we put into our body have been approved by some federal agency, but this is a frontier.
  • Sen. Campbell- has there been use of steroids?
    • Huang – yes
  • Sen. Campbell- is there a second-hand smoke effect with e-cigs and vaping?
    • Hawk – this is unknown at this time.
  • Sen. Campbell- is there a greater chance of oral cancer with these products?
    • Hawk – the studies have not been done to look at this. We do not know the answer to that question.
  • Sen. Campbell- do you have stats on daily use?
    • Maddock – we ask monthly, and counting daily use is difficult. However, our rates have been
  • Sen. Johnson- what has the reaction been to the ban?
    • Maddock – most have been positive, but others have pushed back.
  • Sen. Miles- SB 21. There is a study going on about the vaping liquids. There is a UT initiative. Dr. Maddock, are there any other campuses who have banned?
    • Maddock- there are thousands right now.
  • Sen. Miles- do you think this trend will spread?
    • Maddock- I would be surprised if smoking wasn’t banned on all campuses in 10 years.
  • Sen. Howell- studies on vaping and seizures
  • Sen. Kolkhorst- is there a hypothesis why there are more cases in North Texas?
    • Huang – I believe it is just that our investigations are more robust.
  • Sen. Kolkhorst- when we look at enforcement with minors, it is amazing how accepted it is.
  • Sen. Campbell- depending on how much nicotine is taken in, seizures can occur. Maybe those who get these cases can report those to poison control?
    • Huang – they report to their local health department.

Public Health – Panel 3

Joshua Thigpen, Comptroller’s Office

  • Packets were distributed to tobacco retailers after SB 21 was passed.
  • Employees had to sign forms that stated they received and understood the new information.
  • Created a sticker to simplify SB 21.
  • Inspections were made to retailers in order to make sure they were in compliance.
  • The bill states that individuals must be 21 years old, or fall under one of the two exemptions in order to purchase tobacco products.
  • Regulations differ for taxpayers who sell e-cigarettes do not have any other permitting requirements other than a sales tax permit.
    • Because of this, we are unable to identify retailers who sell only e-cigarettes products to conduct the compliance inspections.
  • Sen. Kolkhorst- could you repeat that statement again?
  • Thigpen repeats the previous statement concerning e-cigarettes permitting requirements and the resulting difficultly of conducting compliance inspections.

Captain Justin Scott, Comptroller’s Office

  • Our mission is to seek out felony tax-evaders.
  • After the comtroller
  • 83 retail location have been targeted, 10 of those were vape and e-cigarettes

Dr. Steven Kelder, UT Public Health

  • Is here to discuss flavors and the research done at UT.
  • Earlier this summer, the FDA announced their plan for rapid removal of e-cigarette flavors.
  • Recently, federal authorities have backed away from the flavor ban, causing many states and municipalities to act on their own.
  • We have been waiting too long for the FDA’s review and enforcement and the crisis in Texas will only grow more severe. E-cigarette and vaping use is up 300% since 2016.
  • Believes e-cigarettes and vaping are safer than combustible cigarettes in terms of cancer.
  • However, many teens use the Juul which has higher levels of nicotine than a regular cigarette.
  • Nicotine is addictive and causes attention and anxiety issues.
  • Teen nicotine users are more likely to experiment with other tobacco products and marijuana.
  • Their toxin content is lower, but still there and linked to cardiovascular and respiratory issues.
  • Notes the THC and vitamin e acetate linked to these diseases.
  • These flavors are still in the marketplace and can provide a pleasurable experience.
  • Discusses statistic findings that show many teens do not know they are smoking nicotine and the large rates of teens who vape/use an e-cigarette are choosing flavored products.
  • Eliminating flavors would disincentivize teens to experiment with e-cigarettes and reduce the likelihood of addiction and adverse consequences.

Carolyn Counce, Texas Association of School Boards

  • Provides an overview on TASB’s services including the legal services provided for school districts.
  • TASB creates student code of conduct is a board adopted document that is required by statute, but additionally, a student handbook that is not board adopted (it is under administrative discretion).
  • Provides a timeline of TASB materials were adjusted to reflect prohibition of e-cigarettes starting in 2013- before the law addressed e-cigarettes on campus.
  • In 2013, we prohibited the use of these products in the student handbook and the model student code of conduct, which 90% of school boards use.
  • After SB 97 in 2015, we updated our policies to reflect the language of the bill.
  • In 2017 there was a provision in SB 489 that specified that the school health advisory council was responsible for recommending instruction to prevent the use of e-cigarettes.
  • The Texas Department of State Health services provided a document of recommendations to districts. Outlines the recommendations including districts enforcing current law and their own district practices.

Eric Mullens, Principal of Hempstead High School

  • Provides a demographic overview of Hempstead High School.
  • In 2017-18 HHS had three vaping incidents. The next school year, the incidents doubled.
  • As a result, a speaker from the Texas Department of State Health Services was brought in to educate staff and students.
  • Describes the presentation and resources that were provided.
  • As of this academic school year, there has only been one reported vaping incident.
  • Sen. Kolkhorst- we are interested to see the positive effects in your district and appreciate the hands-on approach Hempstead ISD has taken.

Questions for Panel 3

  • Sen. Miles- Ms. Counce, has TASB seen any improvement in one particular district in terms of lower vaping rates?
    • Well we do not track vaping incidents, or the type of prevention programs districts use. So, there is no data on that.
  • Sen. Miles- Dr. Kelder, what is the best way to communicate the dangers of vaping to teens?
    • One is through mass media campaigns though the CDC and FDA, but these need to be better funded. The second is school-based programs. UT Public Health has developed the “catch my breath” program which is supported by CVS and is free to schools. 25% of schools are already using it.
  • Sen. Kolkhorst- do schools know where to get that?
    • Dr. Kelder- we are going directly to school districts.
  • Sen. Miles- Ms. Counce, does TASB have any state-wide program similar to what Dr. Kelder is speaking on?
    • TASB does not develop specific materials for student use, we are in policy services, so we are helping districts create their board policies and admin procedures. We rely on third parties, like TDSHS, to make those programs.
  • Sen. Kolkhorst- Ms. Counce, did you say 100% of the school districts are under TASB?
    • Yes.
  • Sen. Kolkhorst- something that would be really easy to do, is to download the link that Dr. Kelder was talking about, and that would be a great place to start. Discusses Hempstead taking things head-on.
    • Counce- we are happy to share resources, but we do not create the materials ourselves.
  • Sen. Miles- Caption Scott, has the Comproller’s office initiated any in-house investigation since the outbreak of vaping-related deaths since 2018?
    • We are charged with enforcing the provisions of 161 and 155 of the tax code.
  • Sen. Miles- so there has been no cross, unifying work with DPS to investigate maybe any Texas company that is selling the vitamin e acetate?
    • Not to my knowledge.
  • Dr. Kelder- there is a company named “Dark Vape” in Illinois that appears to be supplying a lot of the vitamin e acetate.
  • Sen. Miles- Thigpen, has the comptroller’s office developed, with HHS, an address to the popularity of vaping amongst youth?
    • We work in partnership with HHS with an annual, federally-mandated, program where we do undercover stings across the state on retailers. We follow up on any violations with our criminal investigation division who goes out and targets retailers based on the results. Our latest report shows sales down from 11% to approximately 7%.
  • Sen. Miles- would you recommend to the members that we do an enhancement of the penalty for retailers that are selling illegally or selling to minors?
    • We enforce the statute as written, so whatever is provided to us, we will do.
  • Sen. Miles- if we did though, would it help you?
    • If fines were increased, it would possibly have an effect.
  • Sen. Miles- we have raised the taxes on these products, have you seen a decline in sales?
    • It is too early since the passing of SB 21 to track that, but we have seen our retailers enforcing that. There are a lot of agencies who are working to enforce that.
  • Sen. Miles- madame char, I think we should focus on increasing the penalty for selling to minors and possibly come up with a master plan with TEA and the comptroller’s office.
  • Sen. Johnson- Mr. Thigpen, you have established that to sell vape products, you do not need the same kind of sales tax permit as you would if you sold traditional tobacco products. Correct?
    • There is a tobacco permit that is required to sell those products, yes.
  • Sen. Johnson- does it make it difficult to identify which shops are selling vapes to minors?
    • Correct. We are currently searching for key words like “vape” to look up retailors who have a sales tax permit, but we only have 1200 results.
  • Sen. Johnson- would it be easier for you if we had a separate retail license that could be revoked if a retailer sold to minors?
    • If the products had a permit, we could run a drop on that permit.
  • Sen. Johnson- would that disincentivize retailors from selling to minors?
    • I cannot say, but it would help us locate all retailors who are selling and to inspect those retailors. We could also provide them with the information that we provide to all our retailors.
  • Sen. Johnson- If we were to regulate vaping products in this manner, how many retailers have ever had their permit revoked?
    • I do not have that information with me. The only information I could provide you with, as of this year, it would be 0.
  • Sen. Johnson- if you were to estimate past years, would it be greater than 0?
    • Most likely not.
  • Sen. Johnson- does that have something to do with how many times you have to get busted to have your permit revoked? How many times?
    • Yes. To have a permit revoked, you would have to be hit with a violation 5 times in 1 year. With the amount of locations, we have, it would be difficult to hit a single location 5 times.
  • Sen. Johnson- resources do not go that far, correct?
    • Correct.
  • Sen. Johnson- this is problematic, would you agree?
    • Yes. As far as revoking permits, we have specific instructions to follow in chapter 161.
  • Sen. Johnson- I think our committee may be able to help you with that.
  • Sen. Johnson- is there a difference between how we treat cigars and loose tobacco as far as regulations go?
    • No.
  • Sen. Johnson- what proportion of fines are picked up by CID versus local law enforcement.
    • Scott- the locals would have the grants and report the sales to minors violations to us, and we assess the penalties to those retailors. It is mainly local who report those cases to us.
  • Sen. Johnson- what does cooperation with local agencies look like?
    • We often cooperate with local agencies when doing sting operations and they are more likely to reach out to us when they have a problem of complaint and we work together to enforce that.
  • Sen. Campbell- Dr. Kelder, we see earlier presentations of lung diseases in youth versus the more chronic issues with traditional smoking. What is causing the acuteness?
    • It is hard to be exact, but the CDC is working to answer this question. They release a report every Thursday. The vitamin e acetate, THC and other possible ingredients seem to be the culprit. Mentions “Dark Vape” again as a possible culprit.
  • Sen. Kolkhorst- we sell e-cigarettes and vapes online?
    • All- yes.
  • Sen. Kolkhorst- how is that regulated?
    • Thigpen- they follow the same regulations as the tobacco products would. For age verification purposes, they have two options in statute.
  • Sen. Kolkhorst- the number mentioned about how many retailors there are, are they physical locations? Which can be convenience stories?
    • Yes, and all are able to sell vapes and e-cigarettes.
  • Sen. Kolkhorst- in theory, I could have a store that sells clothes and vapes?
    • Yes.
  • Sen. Kolkhorst- does the Texas Alcohol cigarette enforcement?
    • Their agents cover how many cigarettes that can cross the border.
  • Sen. Kolkhorst- so you are charged with enforcement?
    • Yes.
  • Sen. Perry- it does not make a lot of sense to me that the TBC would not be in charge of enforcement, but rather the comptroller’s office is.
  • Sen. Kolkhorst- this is something we will look at and is something to think about. We want to work on the word-search when finding those retailors. 

Health Care Costs Interim Charge

  • Examine the current status and future direction of the following programs: The Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver, including the DSRIP Transition Plan, and the Healthy Texas Women Section 1115 Demonstration Waiver.

Health Care Costs – Panel 1

Emily Blanford, National Conference of State Legislatures

  • Provides overview of 1115 waivers, many states use this for substance abuse benefits and nontraditional Medicaid expansion; waiver allows states to tailor for unique needs
  • 1115 waivers can take more time to implement than other options as negotiation with federal government is time consuming
  • Many states are looking at work requirements in 1115 waivers
  • Some states are experimenting with different waivers like required transportation to medical appointments, services to persons under 21, etc.
  • LTSS waivers, many states are using MCOs for community-based services etc. to move LTSS into less-costly community placements
  • Most 1115 waiver is in behavioral health, particularly in substance abuse; many use waivers to add residential treatment options
  • Delivery system reforms are key parts of behavioral health waivers, big push is to support physical and behavioral health integration

Barbara Eyman, Eyman Associates

  • Has advised states on 1115 waiver implementation
  • Will be reviewing 1115 structure and Trump administration’s application of 1115 concepts
  • Secretary of State has authority through CMS in waivers and providing matching funds, can be used for demonstration projects that assist in promoting objectives of the Medicaid Act
  • TX has been provided waivers to provide managed care, phase it in, and provide benefit packages
  • CMS uses expenditure authority for promising state initiatives, such as the DSRIP and UC pools in TX; have been used in other states for mental illness and substance abuse
  • CMS’ longstanding policy is that projects are budget neutral, can’t spend more than federal government would have without the waiver; savings can be reinvested back into the program
  • CMS approves waivers through the STC agreements, length is expanding; CMS has complete discretion in whether to approve a state’s waiver
  • CMS has a 3-prong approach to working with states on Medicaid; flexibility, accountability & program integrity – sometimes difficult to tell which is going to be emphasized in negotiations, e.g. whether extensions are granted
  • CMS has stated that they want to move forward with a unified approach rather than one-off waivers, many states are responding by creating value-based systems to continue DSRIP work after phase-out
  • CMS has implemented increasingly rigorous evaluations to ensure federal government is getting expected value, also making efforts to ensure taxpayer funds are spent appropriately and STCs are being more strictly followed
  • TX should develop a clear vision of where Medicaid program should be taken and should seek CMS buy-in early on; CMS’ authority is extensive, but discretionary, so CMS should be recruited as a partner early

Matt Salo, National Association of Medicaid Directors

  • It is a challenge in any one state to understand Medicaid, differences between states add to this, but variability is a feature
  • Recently polled states on top priorities for Medicaid Directors, priorities largely lie in delivery system and payment reform and moving Medicaid toward a more holistic system with financial incentives in place to drive quality; essentially transforming business model of Medicaid
  • Most states tend to try this through managed care, incl. TX, AZ, TN using MCOs and paying capitated payments to plans to deliver services
  • Managed care is a means to an end and not an end itself, ongoing effort to ensure state budget is being spent to drive healthcare outcomes; many states approach this using 1115 waivers
  • States are hearing that there are changes coming to the way waivers have been approved and are continued, DSRIP waivers are going away
  • Other things to watch for are federal priorities around fiscal accountability, incl. new rule, could have billions of dollars of impact on states like TX and CA
  • Chair Kolkhorst – Regarding DSRIPs, we’ve set up this elaborate DSRIP program to innovate, TX has one of the largest with over 1,400 programs; if we drop that, where do we go?
    • Eyman – CMS would like a way to sustain this work rather than terminate, which is why they have required states to come up with a transition plan out of DSRIP to emphasize value-based work
    • TX was required to submit a plan and did this Fall, many states are looking at managed care and building funding in for delivery system reform
  • Chair Kolkhorst – So DSRIP payments are now supposed to fold into MCO payments?
    • Eyman – CMS came out with new guidelines, allowed more flexibility for MCOs to spend capitated dollars, could allow states to continue value-based work through them
  • Chair Kolkhorst – On the DSRIP projects, we had a regional approach; waivers allow us to tailor system to the state, but CMS’ desire to standardize works against this
    • Eyman – CMS is trying to find a way to have a more streamlined process for the DSRIP payments, having this through MCOs could be a streamlined way to do this
  • Chair Kolkhorst – It could be, I get bothered by opaqueness and I think this drives our healthcare costs; folding DSRIP projects into MCOs makes me think we won’t have as much transparency
  • Chair Kolkhorst – Agree with the current administration that programs shouldn’t continue without evaluation, some should be shut down, etc.; transparency in folding regional programs into MCOs is concerning
    • Eyman – I understand the concern, I think it can be done through MCOs while still requiring the same level of state oversight, just a different way of flowing the funds through
    • State could set up standards and targets for DSRIP projects, still have applications, etc.
  • Sen. Perry – Are we behind the curve on CMS meetings?
    • Salo – Never to late, very valuable to have a constant conversation with state and federal personnel
    • Should consider how managed care contracts are being written to force transparency
  • Sen. Perry – Regarding the RTC, has an 88% recidivism rate; is there data on the RTCs and addiction programs around?
    • Blanford – Can look into this and get back to you
  • Sen. Perry – Looking for separation of administrative and program costs in the 56 different Medicaid administrators around the states; 56 different authorities and wondering if it’s possible to have a better system, e.g. what is the cost of the bureaucracy to maintain all these different programs and is it possible to save dollars on a national MCO or something similar
    • Salo – Complicated question, administrative versus program costs are measurable, but unsure if this answers what you’re asking
  • Sen. Perry – Would at least be a starting point for conversation
    • Salo – Would caution you not to read into this to much, especially given conversation surrounding social determinants of health, e.g. housing, food, etc. things that are outside program costs
  • Sen. Perry – I don’t have anything to go by right now, but you raise a valid point on social vs. medical
  • Sen. Miles – Asks Salo, TX is one of the leading states in the country with uninsured citizens, TX hasn’t expanded Medicaid for several years; wouldn’t it be smart and prudent to expand Medicaid and Medicare to take more advantage of the 1115 waivers and have wider and larger controlled access to managed care?
    • Salo – That is a question that is above my paygrade, not the decisions of the state Medicaid Directors to do this
  • Sen. Miles – Asks after other states that have taken advantage of Medicaid expansion
    • Salo – Do see more federal dollars, also see more state dollars spent
  • Sen. Miles – Also have more insured and healthier people
  • Chair Koklhorst – Does Medicaid expansion cover noncitizens?
    • Salo – In general no, but with some exceptions like emergency care
  • Chair Kolkhorst – Given mix of noncitizens in TX, even with Medicaid expansion we would still need a robust UC system on top of this
  • Chair Kolkhorst – Regarding the vision for Medicaid, will it be TX’s vision or CMS telling us what this vision is?
    • Eyman – Vision should come from the state, I’m suggesting you come up with this vision and let CMS help you achieve it by getting them onboard early on
  • Chair Kolkhorst – And the work requirement? And the lawsuits on this
    • Blanford – 18 states have applied for work requirement waivers, several lawsuits pending, AK, KY, and NH have had the requirement set aside waiting on appeal
    • Salo – Legal challenge is on predicating coverage based on ability to work or other community engagement targets, e.g. individuals losing coverage if they don’t meet those
    • Eyman – CMS has yet to approve work requirements in non-expansion states
  • Chair Kolkhorst – You mentioned there was a state that expanded women’s healthcare for addiction to 12 months and this was approved?
    • Blanford – MO has enacted legislation, but I don’t think their waiver was approved
  • Chair Kolkhorst – We did work to investigate maternal health outcomes and added programs to Healthy Texas Women, interested to see waiver from CMS
  • Sen. Perry – Asks for NCSL have data regarding Medicaid expansion that would indicate success, failure, unintended consequences, etc., concerned about the possible fiscal cliff
  • Sen. Perry – Would argue that the majority of uninsured persons in the state still receive good healthcare
  • Sen. Perry – We didn’t do 1332, should our vision include 1332?
    • Eyman – 1332 goes beyond Medicaid, parameters around the waiver authority mean it has not been used probably as much as intended, but could fit in the vision
    • Salo – 90/10 is actually the cliff
  • Sen. Perry – So would need to come up with $7 billion, don’t believe we have this
  • Sen. Powell – Asks for clarification from Eyman over statements, concerned that some dollars are leaving the state
    • Eyman explains the budget neutrality principle from the 1115 waiver; savings from the 1115 programs in Texas can be reinvested within the state
  • Chair Kolkhorst – Negotiation leverage for TX is that we could negotiate a good waiver and continue savings or just go back to FFS

Health Care Costs – Panel 2

Charlie Greenberg, Health and Human Services Commission

  • HHSC presentation on 1115 waiver
  • Sept. 2021 is deadline for waiver application & when DSRIP goes to 0, Sept. 2022 is when the current waiver expires
  • Provides overview of 1115 waiver, incl. concept of programs waived from certain Medicaid reqs., budget neutrality req., savings available for reinvestment, etc.
  • Currently on DY9 and under a 5-year extension expiring in 2022
  • Less savings by programs means programs UC become harder to operate
  • CMS has recently implemented reforms on what funding can be used for: 1) requiring rebasing and 2) eliminating unused savings rollover to most recent 5-year period
  • With rebasing, CMS will look at most recent period within the waiver to determine actual costs and port this over to the new “without waiver” number, could mean budget neutrality room is decreased if a state has been very “thrifty”
  • With the savings rollover, CMS previously allowed savings to rollover year to year, but now can only rollover most recent 5 years

Andy Vasquez, Health and Human Services Commission

  • Current waiver is a 5-year extension, with a 4-year step down for the DSRIP program, STCs require a transition plan for sustaining DSRIP practices through this step down
  • One of the key things HHSC has been able to do with DSRIP payments is support value-based initiatives
  • HHSC submitted the DSRIP transition plan on Sept. 30 with feedback from stakeholders
  • Describes the transition plan: plan includes 10 milestones with financial impacts from CMS if these are not achieved & need to be careful of what the state commits to within the plan
  • Milestone timeline included on Pg. 14 of slides
  • Final plan is required by April 1 of 2020, meeting with CMS nearly monthly to review plan and receive feedback
  • Plans won’t yet include what the new programs are, these are part of the milestone development
  • Biggest challenges are the aggressive timeline, how to develop programs that are least like current Medicaid services or for people not currently enrolled in Medicaid, and the IGT funding model; HHSC is doing project planning, data analysis, and working with stakeholders to solve these issues

Dee Budgewater, Health and Human Services Commission

  • Speaking on the 1115 waiver and the Healthy Texas Women program, provides a history of the Healthy Texas Women program
  • Have seen substantial growth in the HTW program since inception, approx. 300k enrolled currently
  • HTW demonstration goals are to increase access, avoid unintended pregnancies, promote outcomes, target common issues like diabetes and obesity, lower overall costs, etc.
  • HHSC submitted an application to CMS for a new 1115 waiver on June 30, 2017, state would receive a 90% federal match for family planning and a normal FMAP for other services, admin services at 50%
  • Other than funding, application did not include changes for the HTW model
  • Waiver negotiations began with CMS in Jan 2018
  • Chair Kolkhorst – How are the negotiations going?
    • We continue to engage with CMS, part of the negotiation process; going well so far
  • Chair Kolkhorst – Missouri’s has not been approved yet?
    • Not yet
  • Sen. Johnson – Has it been 2 and a half years since HHSC first submitted a plan, but no movement yet?
    • Yes, still hoping & responding to CMS
  • Chair Kolkhorst – LPPF’s are still a large part of what we do
  • Sen. Flores – What is the plan if CMS says “no”?
    • Don’t have the info in front of me, but can take it back
  • Sen. Flores – What would you recommend if they say “no”?
    • Would need to weight things out, but above my paygrade
  • Sen. Flores – Good to be hopeful, but need to have alternatives
  • Chair Kolkhorst – Within the budget we have set aside GR, but I think federal partners will want to join us and help expand our program
  • Sen. Johnson – Asks Greenberg, does the HHSC DSRIP transition plan apply between now and 2022 or does it go beyond?
    • Greenberg – Plan touches on both aspects, talks about how plans will be developed through the end of the waiver and after the waiver
  • Sen. Johnson – But it doesn’t bind the state after 2022?
    • We are at risk for milestones still
  • Sen. Johnson – Legislature could come up with something better in perhaps 2021 & we’re not impaired by what we submit to CMS now?
    • I believe so, as long as we reach the milestones

Health Care Costs – Panel 3

Carol Huber, University Health System San Antonio

  • Waiver design includes 20 healthcare partnerships with designated anchor organization, University Health System is the anchor for Regional Healthcare Partnership 6; provides overview of University Health System and RHPs, each RHP is unique and works with hundreds of partners
  • RHPs liaise between HHSC and providers, allow for greater local control through the waiver, providers can make decisions for their communities
  • DSRIP fund value has decreased this year and will decrease further, though there will still be DSRIP funds in the last year, not all providers are eligible for UC & will be devastating if not replaced
  • Waiver is important, promotes health outcomes and bolsters care continuum for all TX
  • Describes structure and geographical makeup of RHPs, was drawn from provider input
  • Outcomes are partially driven by service to low-income and uninsured individuals; good to speak about relying on managed care, but does not do much for uninsured population
  • Anchors do not get in the way of provider reporting, serve mostly as means to disseminate information
  • RHP anchors and providers are very eager to participate in DSRIP transition

John Hawkins, Texas Hospital Association

  • DSRIP funds are important to the healthcare safety net in the state, originally given authority to serve non-Medicaid populations under the assumption that they would fold into expansion
  • New waiver removes Medicaid shortfall bad debt from the UC pool, even with these elements out of the pool we have an increase in the pool with the new dataset
  • Challenges like Medicaid shortfall will continue to exist, need to figure out ways to keep funds in the system so safety net doesn’t fail
  • One of the challenges is the state is not putting up GR for the state share, will ultimately be constrained by entities putting up the IGT
  • RHPs were constructed this way due to other entities putting up the state share; will need to look out how regions line up with managed care service areas as we will ultimately need to run this through managed care
  • Need to work with HHSC on aligning priorities, administrative efficiencies are helpful for all providers
  • Need to look at the directed payments, biggest bang for the buck
  • Hopes this will continue to be centered around the RHP process, good collaboration so far
  • Rural providers have been disadvantaged by the way the state share is worked, will be hardest hit & need to watch this
  • Should look at behavioral health discharge planning, physician services in the community, and palliative care – these things help reduce UC

Lee Johnson, Texas Council on Community Centers

  • Provides overview on Community Mental Health Center structure, history & legislative decisions affecting CMHCs
  • DSRIP allows for many new individuals to gain access to services, the majority of whom are uninsured
  • Should establish Certified Community Behavioral Health Clinic as providers along with payment strategy through managed care
  • Should focus on target individuals with serious mental illness and develop service structures around them
  • Should work on building capacity for integrated care (behavioral health/substance abuse)
  • CCBHC meets directives on directed payments from CMS
  • Currently 10 CCBHC sites in TX< with statewide rollout by Aug 2021
  • Increasing CCBHC sites is included in HHSC’s Blueprint for a Healthy Texas business plan

Doug Curran, Family Doctor

  • Not about politicizing the issue, it is about taking care of patients; 1115 waiver has been an enormous asset for TX and very frightening if it goes away
  • Availability of behavioral health services is a large issue in the state
  • Not doing enough as a state to support low-income or uninsured patients, many visit the ER and state ends up with larger costs
  • Sen. Miles – Agrees with and wants to share the testimony with colleagues
  • Sen. Powell – Shares anecdote of constituent having difficulty securing care; important to find ways to deal with uninsured issue and find way to properly compensate doctors for Medicaid care
  • Sen. Miles – Agrees, asks Curran if he practice in small town TX?
    • Yes
  • Sen. Miles – Likely not many minorities in small town TX, everyone is affected by the fact that Medicare is not expanded across the state
    • Yes, everyone has been affected across the board; health insurance costs have gone up for everyone due to those without

Stephen Williams, Houston Health Department

  • Public Health provides a safety net and prevention services to those unable or unwilling to use traditional services, DSRIP funding allowed for local health departments to expand this greatly
  • Local health department participation in Medicaid moving forward is vital to sustainability, local health departments would need to seek additional funding from local governments and the state for critical public health issues without Medicaid

Yen-Chi Le, UT Health

  • Describes UT Health; have been able to expand through DSRIP with 22 programs and 19 locations, 454 jobs at $52 million in salaries and benefits
  • 1.3 million clinical encounters over past 5 years, 75k encounters for behavioral health, 900k unique patients
  • Highlights 24/7 nurse ER triage line operated by UT Health
  • UT is trying to use non-physician providers to coordinate care, DSRIP has allowed for large numbers of referrals
  • Highlights programs created and expanded under DSRIP; program providing access for those with complex issues has been very successful, likewise postpartum depression program
  • Sen. Miles – Commends UT system, tries very hard to work with community partners
  • Sen. Miles – Asks Williams, Passed SB 2021 in the Senate last session dealing with local health departments and MCOs, but it did not pass the House; can you go into how things would be different if the bill passed
    • Williams – This was aiming to establish a specific provider type for health departments, difficult to integrate into the MCO model
    • A couple requirements are not appropriate for health departments like 24-hour coverage, governments cannot indemnify organizations as this is against the law
  • Sen. Miles – It would have been beneficial for you, will be trying to pass this as well in the 2021 session
    • Williams – Would certainly help from a reimbursement standpoint
  • Chair Kolkhorst – As you see DSRIP and the financial cliff it may be headed toward, what is your thought on this? Medicaid is very expensive and costs has been a real issue, what do we do without DSRIP?
    • Williams – Conceptually it is doable and has been tried in other states with some level of success, would be quite challenging; provides example to highlights how challenging it is to make payments flow correctly
    • Managed care takes care of the majority of individuals, but there are some outliers
    • Le – UT has engaged the MCOs over the past few years, has been engaging with the MCOs; for particular things like pneumonia vaccination of the elderly the DSRIP timeline was easy to handle, but things like care coordination of chronic disease has been more complicated with more difficult to understand ROI
    • Both DSRIP and MCO pay for quality programs are mostly based on HEDIS measures so there is a lot of overlap on quality measures
  • Chair Kolkhorst – When you’re looking at DSRIP projects, these cover those with insurance and the uninsured?
    • Le – Yes, MCOs will take care of a large portion of the community, but still a large number without care
  • Chair Kolkhorst – Houston Hospital District had the gold card?
    • Williams – They don’t call it the gold card, they have an eligibility process
  • Chair Kolkhorst – FQHCs are a part of this, do you coordinate with them through DSRIP?
    • Williams – Chronic homelessness project subcontracted with FQHCs
    • Le – UT tried not to reinvent the wheel, tried hard to form community advisory boards and work with FQHCs in underserved areas in Houston; FQHCs can’t handle all of the volume alone
    • We partner with Houston food bank, etc. to ensure patients can take medication with food
  • Chair Kolkhorst – And these are people that don’t qualify for the Lone Star Card, so they’re not poor enough to qualify, but not rich enough for food?
    • Le – Yes
  • Sen. Miles – Thanks Houston and Williams for innovative thinking in caring for Houston
  • Chair Kolkhorst – Did SB 2021 get a hearing?
    • Sen. Miles – It got passed over here, but did not pass the House
  • Chair Kolkhorst – Does the Houston health department always fight my food freedom movements?
    • Williams – Depends on what they are
  • Chair Kolkhorst – Moving on to public testimony, will be tackling portion of the health care costs charge in pieces over subsequent hearings as well

Spotlight on Public Testimony

Steve Love, DFW Hospital Council

  • DSRIP projects are important because 40-50% of people in these projects would not normally qualify for Medicaid
  • Concerned that if we fold this into managed care there will be qualification question based on Medicaid eligibility, Medicaid expansion would be a safety net for those in Texas
  • Chair Kolkhorst – Our challenge is that the ACA does not cover many of those that need to be seen with Medicaid expansion; partners need to understand the uniqueness of the state

Adrienne Trigg, Protect TX Fragile Kids

  • Wonders if the Committee has considered new federal ACE Kids Act
  • Medically complex and fragile children are small portion of population but account for 40% of Medicaid expenses
  • Chair Kolkhorst – Have encouraged HHSC to be involved in a bill to help wrap this up (HB 4533)

Lindsey Lanagan, Legacy Community Health

  • Provides overview of FQHCs and involvement in 1115 waiver and DSRIP; asks that FQHCs remain at the table in 1115 and DSRIP discussions
  • Sen. Johnson – Asks Love, have you given a lot of thought to Medicaid expansion?
    • Yes, and the American Hospital Association supports Medicaid expansion, will help in the long run to reduce health care expenditures
  • Sen. Johnson – So the state balance sheet wouldn’t be affected?
    • In Dallas County, you get almost $14 back for every $1 put in, effect wouldn’t be more than 10%
  • Sen. Johnson – The 90/10 wouldn’t go away, correct?
    • Correct, have seen other provisions where contract would be broken if it moved below this
  • Sen. Johnson and Love discuss other states that have expanded, Indiana did under Gov. Mike Pence at the time, was done under the 1115 waiver
  • Sen. Johnson – Was there a participation by providers in the Indiana plan that would take some of the burden off the state?
    • In Indiana, providers also helped with upfront costs to help draw down federal funds
  • Sen. Johnson – Any personal responsibility elements in the Indiana plan?
    • Yes, were deductible reqs. etc.
  • Sen. Johnson – Regarding undocumented immigrants and the effect on Medicaid, undocumented immigrants are not eligible for Medicaid unless in an emergency situation, could get the federal government to reimburse
  • Sen. Perry – Out federal government is $22 trillion in debt, need to be careful about working with this especially when the largest growth sector is entitlements
  • Sen. Perry – 90/10 is by rule and not statute, naĂŻve to not acknowledge the issues with fiscal responsibility in the federal government
  • Sen. Johnson – I’ve asked this panel and every panel to address this, should not let ignorance and myth inform the discussion; need to take fiscal concerns seriously and listen to stakeholders
  • Chair Kolkhorst – In our current Medicaid program, those most in need are on wait lists, not able-bodied citizens and desperately need help; took money this past session and finally worked to reduce waitlists, will stay focused on those most fragile in TX
  • Chair Kolkhorst – Undocumented immigrants and costs associated will always be the challenge of TX

Lindy McGee, Texas Pediatric Society, Texas Medical Association, Texas Association of Family Physicians

  • While we’ve been lauding ourselves for reducing rates of smoking among teens, Tobacco industry has been creating new addicts through e-cigarettes
  • Flavors have been banned in traditional cigarettes since 2009, but no such ban for e-cigarettes
  • Lack of regulation and oversight has failed children
  • Support policies like increasing tax on cigarettes, excise tax on e-cigarettes, banning all flavors, and requiring a permit to sell
  • Chair Kolkhorst – Shares anecdote of mother with college aged child, she does not know one person who has not tried vaping
    • I believe this, many patients believe they are just vaping flavors and don’t understand it is nicotine

Jaclyn Finkel, Foundation for an Informed Texas

  • It appears to a significant portion of vaping illnesses resulting from cannabis cartridges are the result of bad actors in the market, e.g. contaminants; other states that regulate require all ingredients to be listed
  • Vaping devices can be used on not only oil, but also the cannabis flower, including hemp flower; need to ensure all CBD/hemp products have ingredients listed and are properly regulated/tested

Bryan Shippey, Westlake High School Assistant Principal

  • Vaping is a student safety concern
  • See the same trends at Westlake as seen nationally, e.g. young males, typically Juul, with fruit-flavored cartridges; many students have no idea what is in the cartridge, no students understand relationship between vaping and smoking
  • Students will not touch unflavored vape cartridges

Charlotte Owen, Texas Freedom League

  • Many rely on vaping products to offramp from cigarettes, can find ways to protect youth while also allowing for this
  • Sen. Perry – Asks Finkel, is it fair to say you are an advocate for e-cigarettes?
    • Finkel, Foundation for an Informed Texas – No, I want to have a fact-based conversation around the cannabis market and illegal products
  • Sen. Perry – So your highlight is bad actors?
    • Yes, and that there needs to be testing
  • Sen. Perry – So in this context, can you give me or espouse any virtue of inhaling nicotine? Does it provide any benefit
    • Here to speak on cannabis
  • Sen. Perry – Is there anyone on the panel that can say nicotine is good because?
    • Owen, Texas Freedom League – Offramping cigarettes is good
  • Sen. Perry – So what we’ve heard today from other panels is that there is no evidence that vaping is getting people off nicotine; frustrates that we’ve spent 4-5 hours of our time on this, if offramping is the goal then we should regulate it similar to Chantix and keep it from  kids
  • Sen. Perry – Nuts to me that we are on this, I have no tolerance for those that say this is not a bad thing; this is a bad thing and they knew it was bad when it was developed
  • Sen. Perry – Legislators have to pick up the cost, until industry will pick up the check, I will be vocal anti-vaping

Justin Gibson, United State Vaping Association, Vintage Vapor LLC

  • Supports the lifesaving technology of vaping, shop has never targeted children
  • Sen. Perry – Did you have vaping products on your shelves with flavors that were appealing to kids?
    • I think everybody enjoys flavors
  • Sen. Perry – So the statement you made that you don’t market towards kids when it has been statistically proven that kids are drawn to these flavors is wrong
    • I have a business that is 21 and up, we do not advertise, and children are not allowed inside, convenience stores are a whole different subject
    • 85% of what we sell are flavored products
  • Sen. Perry – Do you sell a vape product that does not contain nicotine?
    • Yes
  • Sen. Perry – If you sold only vape products that don’t have nicotine would your business see a downturn
    • I’m sure it would
  • Shop’s goal is to help people offramp, have helped thousands to quit smoking and customers appreciate the help
  • Testimony so far has misstated what vape shops do, has treated us like drug dealers
  • Chair Kolkhorst – Have you ever been subjected by a sting operation via the Comptroller?
    • Never been profiled and have not had this, but welcome it
  • Chair Kolkhorst – Wanted to know how rigorous a program we have
    • Not rigorous enough, should get the products out of the convenience stores or fine them, this is causing problems for shops like ours

Patrick Hinson, Lake Travis High School

  • Vaping is a large issue with young people and within high school walls

Jared Chipman, Self

  • Blanket ban on flavored products is harmful and will push people towards cigarettes, recent problems are due to black market THC products and not flavored products
  • Products like Juul with high nicotine levels are driving recent issues; Juul pulled products and are still seeing rising teenage use
  • Moving nicotine products to adult-only shops would positively effect youth vaping

James Hubbard, SFATA

  • There is a misunderstanding that all vaping is them same, big difference between open vaping systems and closed systems like Juul; even larger difference between these and black market THC products
  • Flavor of e-cigarettes is not the issue, but the buzz they receive from the high-nicotine Juul
  • Concerned that a black market will develop in nicotine vaping if flavors are banned; should limit youth access to e-cigarettes rather than ban on flavors and should consider limiting nicotine content in products
  • Sen. Perry – Of your client base, how many are there for getting off tobacco products rather than recreational use?
    • Would say 95% of our clientele, ours is an older population
  • Sen. Perry – Getting conflict about the nicotine component, without a nicotine component there is no addiction, is it possible for addictions to come from vaping products?
    • We ask potential customers if they currently smoke, if they say “no” then we do not sell them products with nicotine in them
  • Sen. Perry – So the person who said kids wouldn’t touch these without flavors, is that true?
    • I don’t believe that is true, kids are looking for the buzz
  • Sen. Perry – Nicotine has an addictive quality
    • Industry is about working people off of combustible cigarettes
  • Sen. Perry – Why wouldn’t it be okay for people working off of nicotine addiction to come in with a prescription like for Chantix treatment?
    • I couldn’t afford to have a pharmacist sitting in my store
  • Sen. Perry – You can appreciate the irony from my perspective that this is presented as a method off of tobacco

Steve Love, DFW Hospital Council

  • Enforcement is a real problem, would hope the Committee considers taxes, enforcement, flavor bans; these measures would really help
  • Chair Kolkhorst – 70-80% of those that vape use Juul, getting a lot of input today, but concerns remain

Steve Ross, Texans for Safe & Drug Free Youth

  • Number of youth in Texas secondary schools that are using at least once a month has quadrupled since 2012
  • Long-term effects of these products are not known, the products are easy to hide, and the price is very attractive to young people

Brett Cappolo, The American E-Liquid Manufacturing Standards Association

  • Youth vaping is a sensitive subject and SB 21 is not doing its job
  • Many states thought banning flavors would solve the issue, but the problem is illicit cannabis products
  • Rather than banning flavors, focus should be on youth acquisition, should also ensure that adult Texans have access to adult products
  • Chair Kolkhorst – Epidemic is not with the adults trying to taper down, problem is with numbers escalating in high school and habits exacerbated in college; unsure how we are going to taper individuals off who have gotten addicted to products
    • FDA regulates the industry and responsible actors were required to submit ingredients by Nov. 2018; no responsible manufacturers are using Vitamin E acetate
  • Sen. Perry – You manufacture the liquids?
    • Yes
  • Sen. Perry – Do you manufacture liquids without nicotine?
    • Absolutely
  • Sen. Perry – What is the sales of non-nicotine products, who buys these
    • Could be habitual, could provide sales breakdown
  • Sen. Perry – If we did not have someone die because E acetate, we would not be having this conversation; we’ve created a new generation of kids that will be asking later how they taper off & costs of this addiction are unknown
  • Sen. Perry – Your industry created a new addiction; discussion seems to be to focus on the “bad guys,” but the whole industry seems to be the “bad guy” in marketing this to consumers
    • Two very different products in this space, salt nicotine and freebase nicotine; salt nicotine is an entirely different animal
  • Sen. Perry – Asks again for sales breakdowns, would be indicative of some of the testimony heard today
  • Chair Kolkhorst – When you make flavored products, do they come from sugars?
    • Most are artificial food grade flavors, but with the understanding that not all products are safe for inhalation
  • Chair Kolkhorst – Over time, there is going to have to be a lot of research, have concerns over creating a generation of addiction
    • Ross, Texans for Safe & Drug Free Youth – Recent study showed 63% of youth did not know nicotine was involved in vaping

Shaun Pettit, All About Vapor, SFATA

  • Have two distinct issues: lung injury issue mostly caused by illicit THC products and youth usage; finding out source of youth usage problem is the issue
  • 90% of underage sales are occurring in convenience stores, need to address this on its own and not be confusing it
  • Sen. Perry – I think TABC could provide data on underage sale of alcohol and see if it correlates to convenience stores; laws we make would likely not influence this
  • Chair Kolkhorst – Interesting as TABC does alcohol and Comptroller does tobacco and vaping products, should be some coordination
  • Sen. Perry – We’ve had laws on the books to not sell alcohol to minors from convenience stores since conception and would be interesting to see noncompliance
    • Can look at FDA data, there is data on violations and vast majority is convenience store violation; need to limit access to curb teen usage

Teri Stegall, All About Vapor, SFATA

  • Shares experience of vaping helping to curb heavy cigarette usage
  • All About Vapor shop has contributed large amounts of sales tax revenue to the state; should consider all info

Courtney Mendoza, All About Vapor, SFATA

  • Right of citizens to vape, many Texans vape and like to vape flavors
  • Sen. Perry – As public officials, youth vaping issue is huge and cannot be ignored
    • Legal consenting adults should not be punished
  • Chair Kolkhorst – Have not taken away rights of adults, flavors were not part of the charge, but the testimony today did include this