This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives. STORAGE NAME: h0731b.HHS DATE: 2/1/2022 HOUSE OF REPRESENTATIVES STAFF ANALYSIS BILL #: CS/HB 731 Drug-related Overdose Prevention SPONSOR(S): Professions & Public Health Subcommittee, Caruso TIED BILLS: IDEN./SIM. BILLS: SB 544 REFERENCE ACTION ANALYST STAFF DIRECTOR or BUDGET/POLICY CHIEF 1) Professions & Public Health Subcommittee 15 Y, 0 N, As CS Woodruff McElroy 2) Health & Human Services Committee 20 Y, 0 N Woodruff Calamas SUMMARY ANALYSIS An overabundance of opioids in the body can lead to a fatal overdose. Opioid antagonists are used in opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdose victim to breathe normally. Current law authorizes a health care practitioner to prescribe and dispense an emergency opioid antagonist to a patient or caregiver, and pharmacists may dispense an emergency opioid antagonist pursuant to a prescription or pursuant to a non-patient specific standing order. A patient or caregiver can store and possess approved emergency opioid antagonists and, in an emergency, when a physician is not immediately available, administer the emergency opioid antagonists to a person believed in good faith to be experiencing an opioid overdose, regardless of whether the person has a prescription. Emergency responders and crime laboratory personnel are authorized to possess, store, and administer emergency opioid antagonists. Current law affords civil liability immunity to anyone who possesses, administers, prescribes, dispenses, or stores an approved emergency opioid antagonist. Current law authorizes, but does not require, emergency medical technicians and paramedics who provide basic and advanced life support services to report controlled substances overdoses to the Department of Health (DOH). Current law neither authorizes nor requires hospital emergency departments and urgent care centers that treat suspected or actual overdoses to report such information. This creates a potential gap in the data related to any person that was not transported by a basic life support service or an advanced life support service to a hospital or urgent care center. The Florida Public Health Institute (Institute) is a not-for-profit corporation established by s. 381.98, F.S., with the purpose of advancing the knowledge and practice of public health, including promoting health awareness in Florida. The law requires the Institute, in consultation with DOH, to coordinate monthly health awareness campaigns with national, state, and local health care organizations and government entities on numerous topics, including substance abuse. CS/HB 731 amends s. 381.887, F.S., to allow pharmacist to order and dispense an emergency opioid antagonist to a patient or caregiver without a prescription or pursuant to a non-patient specific standing order. The bill also requires the Institute, in consultation with DOH, to educate the public regarding the use of emergency opioid antagonists. The bill expressly authorizes personnel of a law enforcement agency or other agency, including correctional probation officers and child protective investigators, to possess, store, and administer emergency opioid antagonists. The bill also requires hospital emergency departments and urgent care centers to report the treatment of suspected or actual overdose victims, under certain circumstances. The bill has a negative, insignificant, recurring fiscal impact on DOH that can be absorbed within existing resources. There is no fiscal impact on local government. The bill provides an effective date of July 1, 2022. STORAGE NAME: h0731b.HHS PAGE: 2 DATE: 2/1/2022 FULL ANALYSIS I. SUBSTANTIVE ANALYSIS A. EFFECT OF PROPOSED CHANGES: Background Opioids Opioids are psychoactive substances derived from the opium poppy, or their synthetic analogues. 1 They are commonly used as pain relievers to treat acute and chronic pain. An individual experiences pain because of a series of electrical and chemical exchanges among the individual’s peripheral nerves, spinal cord, and brain. 2 Opioid receptors occur naturally and are distributed widely throughout the central nervous system and in peripheral sensory and autonomic nerves. 3 When an individual experiences pain, the body releases hormones, such as endorphins, which bind with targeted opioid receptors. 4 This disrupts the transmission of pain signals through the central nervous system and reduces the perception of pain. 5 Opioids function in the same way by binding to specific opioid receptors in the brain, spinal cord and gastrointestinal tract, thereby reducing the perception of pain. 6 Opioids include prescription medications used to treat pain, as well as illegal drugs. Opioids include 7 : Buprenorphine (Subutex, Suboxone) Codeine Fentanyl (Duragesic, Fentora) Heroin Hydrocodone (Vicodin, Lortab, Norco) Hydromorphone (Dilaudid, Exalgo) Meperidine Methadone Morphine Oxycodone (OxyContin, Percodan, Percocet) Oxymorphone Tramadol U-47700 In 2019, an estimated 62 million people used opioids for non-medical reasons worldwide. 8 Opioids are commonly abused, with an estimated 36.3 million people worldwide suffering from drug use disorders. 9 Opioids can create a euphoric feeling because they affect the regions of the brain involved with pleasure and reward, which can lead to abuse. 10 Continued use of these drugs can lead to the 1 World Health Organization, Opioid Overdose, https://www.who.int/news-room/fact-sheets/detail/opioid-overdose (last visited Jan. 4, 2022). 2 Medical News Today, What is pain, and how do you treat it? (Sept. 7, 2020), https://www.medicalnewstoday.com/articles/145750#:~:text=People%20feel%20pain%20when%20specific,immediate%20contraction% 20of%20the%20muscles (last visited Jan. 4, 2022). 3 Gjermund Henriksen, Frode Willoch, Imaging of Opioid Receptors in the Central Nervous System, Brain (2008) 131 (5): 1171-1196. 4 Id. 5 Id. 6 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, SAMHSA Opioid Overdose Toolkit: Facts for Community Members (2018). 7 Florida Department of Law Enforcement, Drugs Identified in Deceased Persons by Florida Medical Examiners 2019 Report, (Nov. 2020). 8 United Nations Office on Drugs and Crime, World Drug Report 2021, Global Overview: Drug Demand and Drug Supply (Jun. 2021), WDR21_Booklet_2.pdf (unodc.org) (last visited Jan. 4, 2022). 9 Id. 10 National Institute on Drug Abuse, How Do Opioids Affect the Brain and Body?, (June 2020) http://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/how-do-opioids-affect-brain-body (last visited Jan. 4, 2022). STORAGE NAME: h0731b.HHS PAGE: 3 DATE: 2/1/2022 development of tolerance and psychological and physical dependence. 11 This dependence is characterized by a strong desire to take opioids, impaired control over opioid use, persistent opioid use despite harmful consequences, a higher priority given to opioid use than to other activities and obligations, and a physical withdrawal reaction when opioids are discontinued. 12 Opioid Overdose An overabundance of opioids in the body can lead to a fatal overdose. In addition to their presence in major pain pathways, opioid receptors are also located in the respiratory control centers of the brain. 13 Opioids disrupt the transmission of signals for respiration in the identical manner that they disrupt the transmission of pain signals. This leads to a reduction, and potentially cessation, of an individual’s respiration. Oxygen starvation will eventually stop vital organs like the heart, then the brain, and can lead to unconsciousness, coma, and possible death. 14 Within 3-5 minutes without oxygen, brain damage starts to occur, soon followed by death. 15 However, this does not occur instantaneously as people will commonly stop breathing slowly, minutes to hours after the drug or drugs were used. 16 An opioid overdose can be identified by a combination of three signs and symptoms referred to as the “opioid overdose triad”: 17 Pinpoint pupils. Unconsciousness. Respiratory depression. The rise in opioid overdose deaths can be outlined in three distinct waves: 1. The first wave began with increase prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids increasing since at least 1999. 2. The second wave began in 2010, with rapid increase in overdose deaths involving heroin. 3. The third wave began in 2013 with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl. The market for illicitly manufactured fentanyl continues to change, and it can be found in combination with heroin, counterfeit pills, and cocaine. 18 More than 70,000 Americans died from drug-involved overdose in 2019, including illicit drugs and prescription opioids. 19 Overall, drug overdose deaths increased from 2018 to 2019 with 70,630 drug overdoses reported in 2019. 20 The following graph provides information on the total number of U.S. overdose deaths involving any opioid 21 from 1999 to 2019. 22 Opioid-involved overdose deaths increased from 21,088 in 2010 to 47,600 in 2017, and remained steady in 2018 with 46,802. 23 This was following by a significant increase in 2019 to 49,860 overdose deaths. 24 Opioid Deaths in the United States 11 Supra note 6. 12 Supra note 1. 13 Pattinson, K.T.S., Opioids and the Control of Respiration, BJA, Vol. 100, Issue 6, Pages 747-758. https://doi.org/10.1093/bja/aen094. 14 Harm Reduction Coalition, Guide to Developing and Managing Overdose Prevention and Take-Home Naloxone Projects, (Aug. 31, 2020) http://harmreduction.org/our-work/overdose-prevention/ (last visited Jan. 4, 2022). 15 Id. 16 Id. 17 Supra note 1. 18 Centers for Disease Control and Prevention, Understanding the Epidemic, https://www.cdc.gov/drugoverdose/epidemic/index.html (last visited Jan. 4, 2022). 19 National institute on Drug Abuse, Overdose Death Rates, https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death- rates (last visited Jan. 4, 2022). 20 Id. 21 Any opioid includes prescription opioids (natural and semi-synthetic opioids and methadone), heroin and synthetic opioids other than methadone (primarily fentanyl). 22 Supra note 19. 23 Id. 24 Id. STORAGE NAME: h0731b.HHS PAGE: 4 DATE: 2/1/2022 In 2019, Florida reported 5,268 opioid overdose deaths. 25 This was an 11.9 percent increase from 2018. 26 Florida also experienced 4,152 opioid and 10,464 all drug non-fatal overdoses between July and September 2019. 27 With the onset of the COVID-19 pandemic, the incidence of opioid use disorder and resulting overdose deaths has once again risen. A report from Project Opioid details provisional data from the Florida Department of Health (DOH) showing that deaths from drug overdoses have increased by 43 percent between 2019 and 2020, from 56 deaths per 100,000 in 2019 to 94 deaths per 100,000 in 2020. 28 Additionally, fentanyl, an extremely potent opioid drug, is the leading cause of overdose deaths in Florida, and the incidence of fentanyl overdose deaths increased by 38 percent from 2,348 in 2019 to 3,244 in 2020. 29 Opioid Antagonists An opioid antagonist, such as Narcan or Naloxone, is a drug that blocks the effects of exogenously administered opioids. Opioid antagonists are used in opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdose victim to breathe normally. 30 This occurs because opioid antagonists create a stronger bond with opioid receptors than opioids. This forces the opioids from the opioid receptors and allows the transmission of signals for respiration to resume. 31 This effect lasts only for a short period of time 32 with the narcotic effect of the opioids returning if still present in large quantities in the body. In this scenario, additional doses of an opioid antagonist would be required and it is why it is generally recommended that anyone who has experienced an overdose seek medical attention. 25 Center for Disease Control and Prevention, Drug Overdose Deaths, https://www.cdc.gov/drugoverdose/data/statedeaths/drug- overdose-death-2019.html (last visited Jan. 4, 2022). 26 Center for Disease Control and Prevention, 2018-2019 Drug Overdose Death Rate Increase, https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-2019.html (last visited Jan. 17, 2022). 27 Florida Department of Health, Non-Fatal Opioid and All Drug Overdose Surveillance Report, Florida Q4-2019, http://www.floridahealth.gov/statistics-and-data/fl-dose/_documents/non-fatal-od-2019-q4.pdf 28 Project Opioid, A Pandemic Fueling an Epidemic in Florida in 2020, https://projectopioid.org/wp-content/uploads/2020/12/PO-2020- Data-Study-Final_New-Section.pdf (last visited Jan. 4, 2022). 29 Id. 30 Harm Reduction Coalition, Understanding Naloxone, (Sept. 8, 2020) http://harmreduction.org/issues/overdose- prevention/overview/overdose-basics/understanding-naloxone/ (last visited Jan. 4, 2022). 31 Supra note 13. 32 The half-life for a common opioid antagonist in adults ranged from 30 to 81 minutes. Acute opiate withdrawal is a potential side-effect of naloxone; however, this would be time limited to the half-life of naloxone. STORAGE NAME: h0731b.HHS PAGE: 5 DATE: 2/1/2022 The following map provides information on pharmacy locations where naloxone is available. 33 Florida law allows an authorized health care practitioner to prescribe and dispense an emergency opioid antagonist to a patient 34 or caregiver, and pharmacists may dispense an emergency opioid antagonist pursuant to a prescription for a specific patient or pursuant to a non-patient specific standing order. 35 Current law defines a “caregiver” as a family member, friend, or person that has recurring contact with a person at risk of experiencing an opioid overdose. 36 Therefore, an authorized health care practitioner may prescribe and a pharmacist may dispense opioid antagonists to any person at risk of experiencing an opioid overdose or to any person that has recurring contact with a person at risk of experiencing an opioid overdose. 33 New America, National Naloxone Access Map, https://opioidepidemic.maps.arcgis.com/home/item.html?id=153b0c32fefc432eae6a0e8439b9f56b (last visited Jan. 4, 2022). The National Naloxone Map accumulates data from many difference sources, with participation from thousands of CVS, Walmart, and Walgreens pharmacies, along with other independent distributors. The map is meant to be a community effort, and contributing locations is encouraged to participate, to make it the best possible representation of resources. The map is not complete, and naloxone prescription needs and costs vary by state. 34 S. 381.887(1)(e), F.S., defines “patient” as a person at risk of experiencing an opioid overdose. 35 S. 381.887, F.S. 36 S. 381.887(1)(c), F.S. STORAGE NAME: h0731b.HHS PAGE: 6 DATE: 2/1/2022 Pursuant to s. 381.887, F.S., the State Surgeon General issued a statewide Standing Order for Naloxone in September 2021. 37 The Standing Order authorizes pharmacists to dispense certain naloxone formulations to emergency responders for administration to persons exhibiting signs of opioid overdose. 38 Under the Standing Order, emergency responders, including law enforcement, firefighters, paramedics, and emergency medical technicians, can go to a pharmacy or community-based program for training on opioid antagonist administration and receive an opioid antagonist without a patient- specific prescription. 39 Any person prescribed an opioid antagonist, or distributed an emergency opioid antagonist pursuant to a non-patient-specific standing order, may store and possess approved emergency opioid antagonists. In an emergency, when a physician is not immediately available, that person may administer the emergency opioid antagonists to an individual believed in good faith to be experiencing an opioid overdose, regardless of whether that person has a prescription for an emergency opioid antagonist. 40 Current law also allows emergency responders and crime laboratory personnel to possess, store, and administer emergency opioid antagonists. 41 A person who possesses, administers, prescribes, dispenses, or stores an approved emergency opioid antagonist is afforded the civil liability immunity protections under s. 768.13, F.S. (Good Samaritan Act). 42 Current law does not allow a pharmacist to order an opioid antagonist for a patient or caregiver, or to dispense an opioid antagonist, without a prescription or pursuant to a non-patient specific standing order. Overdose Treatment Reporting In 2017, U.S. drug overdose deaths increased 9.6% from 2016. Emergency departments treated 967,615 nonfatal drug overdoses in 2017. 43 From 2016 to 2017, rates for nonfatal overdoses increased for those involving all drugs (4.3%), all opioids (3.1%), nonheroin opioids (3.6%), heroin (3.6%), and cocaine (32.9%). 44 The following table provides information on emergency department visits related to heroin and nonmedical use of prescription opioids by age from April 2019 to December 2020. 45 Patients aged 26 to 45 accounted for more than half (52%) of emergency department visits related to non-medical use of prescription opioids. 46 37 Florida Department of Health, State of Florida, Statewide Standing Order for Naloxone (Feb. 25, 2019), http://www.floridahealth.gov/licensing-and-regulation/ems-system/_documents/standing-order-naloxone.pdf; Florida Department of Health, State of Florida, Statewide Standing Order for Naloxone (Sept., 14, 2021), https://www.floridahealth.gov/licensing-and- regulation/ems-system/_documents/standing-order-naloxone.pdf. 38 Florida Department of Health, State of Florida, Statewide Standing Order for Naloxone (Sept. 2021), https://floridaspharmacy.gov/pdfs/standing-order-naloxone-9.22.21.pdf. 39 New America, National Naloxone Access Map, https://opioidepidemic.maps.arcgis.com/home/item.html?id=153b0c32fefc432eae6a0e8439b9f56b (last visited Jan. 4, 2022). The National Naloxone Map accumulates data from many difference sources, with participation from thousands of CVS, Walmart, and Walgreens pharmacies, along with other independent distributors. The map is meant to be a community effort, and contributing locations is encouraged to participate, to make it the best possible representation of resources. The map is not complete, and naloxone prescription needs and costs vary by state, but this effort represents over 25,000 locations to obtain naloxone. 40 S. 381.887(3), F.S. 41 S. 381.887(4), F.S. 42 S. 381.887(5), F.S. 43 Centers for Disease Control and Prevention, Nonfatal Drug Overdoses Treated in Emergency Departments – United States, 2016- 2017, (Apr. 3, 2020), https://www.cdc.gov/mmwr/volumes/69/wr/mm6913a3.htm (last visited Jan. 10, 2022). 44 Id. 45 U.S. Department of Health, Substance Abuse and Mental Health services Administration, DAWN: Heroin and Nonmedical Use of Prescription Opioids, https://www.samhsa.gov/data/sites/default/files/reports/rpt32814/DAWN%20Opioids%20Profile.pdf (last visited Jan. 4, 2022). 46 Id. STORAGE NAME: h0731b.HHS PAGE: 7 DATE: 2/1/2022 Emergency Responder Overdose Reporting Current law authorizes, but does not require, emergency medical technicians 47 (EMT) and paramedics 48 to report controlled substances overdoses to DOH. A report must contain: The date and time of the overdose. The address of where the patient was picked up or where the overdose took place. Whether an emergency opioid antagonist was administered. Whether the overdose was fatal or non-fatal. Additionally, the report must include the approximate age and gender of the patient and the suspected controlled substance involved in the overdose, if permitted by its reporting mechanism. Reporters must attempt to make the report within 120 hours. These reports must be filed with DOH using the Emergency Medical Tracking and Reporting System (EMSTARS) 49 or the Washington/Baltimore High Intensity Drug Tracking Overdoes Detection Mapping Application Program. 50 Section 395.1041(6))(b), F.S., requires hospitals with an emergency department to develop a best practices policy to promote the prevention of unintentional drug overdoses. The policy may include, but is not limited to: 47 S. 401.23(11), F.S., defines an EMT as a person who is certified by DOH to perform basic life support. 48 S. 401.23(17), F.S., defines a paramedic as a person who is certified by DOH to perform basic and advanced life support. 49 DOH maintains the EMSTARS to collect data and analyze the incident level data from EMS agencies for benchmarking and quality improvement initiatives. The electronic patient care records submitted by licensed EMS agencies to EMSTARS are confidential and exempt pursuant to s. 401.30(4), F.S. 50 The Washington/Baltimore High Intensity Drug Trafficking Area (HIDTA) is a federal grant program administered by the White House Office of National Drug Control Policy which provides resources to assist federal, state, local, and tribal agencies coordinate activities that address drug trafficking. HIDTA created an app, known as the Overdose Detection Mapping Application Program, which allows EMS agencies to report overdose incidents that are then transmitted in real time with electronic map showing the location, date, time, and incident type. The app does not allow EMS agencies to report on the patient’s age or gender or suspected controlled substance involved in the overdose. 0.30% 2.30% 12.30% 16.10% 63.90% 51.50% 23.40% 30.00% 0% 10% 20% 30% 40% 50% 60% 70% Heroin Nonmedical Use of Prescription Opioids Emergency Department Visits for Heroin and Nonmedical Use of Prescription Opioids by Age from April 2019 to December 2020 Under 1818 to 2526 to 45Over 45 STORAGE NAME: h0731b.HHS PAGE: 8 DATE: 2/1/2022 A process to obtain a patient’s consent to notify next of kin, and each physician or health care practitioner who prescribes a controlled substance to the patient, regarding the patient’s overdose, the patient’s location, and the nature of the substance or controlled substance involved in the overdose. A process for providing the patient or the patient’s next of kin with information about licensed substance abuse treatment services. Guidelines for emergency department health care practitioners authorized to prescribe controlled substances to reduce the risk of opioid use, misuse, and addiction. The use of licensed or certified behavioral health professionals or peer specialists in the emergency department to encourage the patient to seek substance abuse treatment. The use of screening, brief intervention, and referral to treatment protocols in the emergency department. While EMTs and paramedics are expressly authorized to report such information, hospital emergency departments and urgent care centers that treat suspected or actual overdoses are neither expressly authorized nor required to report information. This creates a potential gap in the data related to any person that was not transported by a basic life support service or an advanced life support service to a hospital or urgent care center. The Florida Public Health Institute, Inc. The Florida Public Health Institute (Institute) is a not-for-profit corporation established by s. 381.98, F.S., with the purpose of advancing the knowledge and practice of public health, including promoting health awareness in Florida. The Institute is tasked with procuring funds to complement, supplement, and enhance the missions of the various organizations, entities, and departments that provide public health initiatives by serving as the lead corporation in the state for promoting public health awareness. The Institute is required to enter into partnerships with providers of continuing education for health care practitioners, including, but not limited to, hospitals and state and local medical organizations, to ensure that practitioners are aware of the most recent and complete diagnostic and treatment tools. Additionally, s. 381.981, F.S., requires the Institute, in consultation with DOH, to coordinate monthly health awareness campaigns, with national, state, and local health care organizations and government entities, targeting a wide range of the public, including parents, teachers, other school employees, students in 4 th through 12 th grade, colleges, universities, state agency employees, county and local government employees, patents of county health departments, Medicaid recipients, health care professionals and providers, and the public in general. The health awareness campaigns must include specific diseases in at least one monthly campaign every 24 months. 51 Effect of Proposed Changes Opioid Antagonists CS/HB 731 amends s. 381.887, F.S., to allow a pharmacist to order and dispense an emergency opioid antagonist to a patient or caregiver without a prescription or a non-patient specific standing order. Allowing pharmacist to order opioid antagonists, and dispense the opioid antagonists pursuant to that order, increases access and availability to those that may need an opioid antagonist, especially those not covered by the state standing order for first responders, or by a standing order issued by a corporate pharmacy medical director. The bill expressly authorizes personnel of a law enforcement agency or other agency, including, but not limited to, correctional probation officers and child protective investigators to possess, store, and 51 S. 381.981(2)(a) requires campaigns for cancer, including breast, prostate, cervical, ovarian, colorectal, and skin cancer and leukemia; heart disease; stroke; lung disease, including asthma and smoking-relating disease; neurological disorders and disease, including Alzheimer’s disease, Parkinson’s disease, and epilepsy; gastrointestinal disease; kidney disease; diabetes; liver disease; autoimmune disorders; birth defects and prenatal care; obesity and malnutrition; sexually transmissible disease; hepatitis A, hepatitis B, and hepatitis C; arthritis; vaccine-preventable disease; infectious diseases, including HIV/AIDS; substance abuse; mental illness; lupus; and osteoporosis. STORAGE NAME: h0731b.HHS PAGE: 9 DATE: 2/1/2022 administer emergency opioid antagonists. Personnel of a law enforcement agency or other agency are immune from civil liability or criminal liability as a result of administering an emergency opioid antagonist. Further, the bill amends s. 381.887, F.S., to specify that the purpose of the section is for the prescribing, ordering, and dispensing of emergency opioid antagonist to reflect the changes made by the bill. Overdose Treatment Reporting The bill amends s. 395.1041, F.S., to require hospital emergency departments and urgent care centers that treat a person with a suspected or actual overdose of a controlled substance to report such information to DOH, if that person was not transported by a basic life support service or an advanced life support service. When making such a report, hospital emergency departments and urgent care centers must use best efforts to make the report to DOH within 120 hours after discovering an incident. The bill requires reports to be made using an appropriate method with secure access, including, but not limited to, the Washington/Baltimore High Intensity Drug Trafficking Overdose Detection Mapping Application Program or other program identified by DOH through rule. Emergency Opioid Antagonist The bill amends s. 395.1041, F.S., to require the Institute, in consultation with DOH, to educate the public regarding the use of emergency opioid antagonists. The bill provides an effective date of July 1, 2022. B. SECTION DIRECTORY: Section 1: Amending s. 381.887, F.S., relating to emergency treatment for suspected opioid overdose. Section 2: Amending s. 381.981, F.S., relating to health awareness campaigns. Section 3: Amending s. 395.1041, F.S., relating to access to emergency services and care. Section 4: Providing an effective date. II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT A. FISCAL IMPACT ON STATE GOVERNMENT: 1. Revenues: None. 2. Expenditures: DOH will incur a $64,000 recurring cost for ongoing maintenance, additional data storage, and software licensing related to the reporting requirements required by the bill. This cost can be absorbed within existing resources. B. FISCAL IMPACT ON LOCAL GOVERNMENTS: 1. Revenues: None. STORAGE NAME: h0731b.HHS PAGE: 10 DATE: 2/1/2022 2. Expenditures: None. C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR: None. D. FISCAL COMMENTS: None. III. COMMENTS A. CONSTITUTIONAL ISSUES: 1. Applicability of Municipality/County Mandates Provision: Not applicable. The bill does not appear to affect county or municipal governments. 2. Other: None. B. RULE-MAKING AUTHORITY: DOH has sufficient rulemaking authority to implement the bill’s provisions. C. DRAFTING ISSUES OR OTHER COMMENTS: None. IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES