Health and Human Services (HHS) Policy Committee

A RESOLUTION ON MEDICAL MARIJUANA

WHEREAS, the battle over legal medical cannabis represents a monumental moment for states’ rights;

WHEREAS, the use of cannabis for medical purposes has been legalized in twenty-nine states and the District of Columbia, while seventeen states have more restrictive laws;

WHEREAS, the medicinal use of cannabis is a concept that spans tens of thousands of years and many cultures, both ancient and modern; 93 percent of Americans supported the legal, medical use of cannabis in a recent Quinnipiac poll;

WHEREAS, medical research indicates that cannabis can alleviate chronic pain and muscle spasms, reduce nausea and vomiting in chemotherapy patients, and improve appetite in HIV/AIDS patients; and

WHEREAS, cannabis is also recommended for anorexia, arthritis, migraines, and glaucoma when traditional treatments are ineffective.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) urge Congress to amend legislation to remove Marijuana from schedule I and reclassify it in a category that, at a minimum, will recognize cannabis as a drug with potential medical value;

BE IT FURTHER RESOLVED, that the NBCSL urges and encourages the United States Congress to enact a statute prohibiting the federal government from interfering with implantation of states’ medical cannabis laws; and

BE IT FURTHER RESOLVED, that the NBCSL encourages the commission of a study to explore the fiscal impacts associated with the decriminalization or reclassification of marijuana for people of color; and

BE IT FINALLY RESOLVED, that a copy of this resolution is transmitted to the President of the United States, the Vice President of the United States, members of the United States House of Representatives and the United States Senate, the U.S. Department of Justice, and other federal and state government officials as appropriate.

• SPONSOR: Representative Larry Miller (TN)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ON PREVENTION OF LAWSUITS THAT AFFECT PATIENTS USE OF PRESCRIBED MEDICATIONS

WHEREAS, misleading lawsuit advertising is scaring away people from taking their prescribed medications and seeking treatment;

WHEREAS, the American Medical Association has recognized, “fearmongering” lawsuit ads pose a threat to public health;

WHEREAS, unscrupulous firms-often non-attorney “lead generation” companies – have violated patient privacy by obtaining and using private health information to identify and solicit individual to file lawsuits; and

WHEREAS, a person engages in a deceptive trade practice if in advertising legal services the person does any of the following:

• Fails to disclose at the outset of the advertisement: This is a paid advertisement for legal services”;
• Presents an advertisement as a “medical alert, “health alert,” consumer alert,” “public service announcement” or similar term;
• Displays the logo of a federal or state government agency in a manner that suggests affiliation with or the sponsorship of that agency;
• Uses the word “recall” when referring to a product that has not been recalled by a government agency or through an agreement between a manufacturer and government agency;
• Fails to identify the sponsor of the advertisement; or
• Fails to indicate the identity of the attorney or law firm that will represent clients, or how cases will be referred to attorneys or law firm that will represent clients if the sponsor of the advertisement may not represent persons responding to the advertisement.

THEREFORE, BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) affirms that a person shall not use, cause to use, obtain, sell, transfer, or disclose to another person without written authorization protected health information for the purpose of soliciting an individual for legal services and that a violation of this constitutes a (violation of health privacy law) or (deceptive trade practice);

BE IT FURTHER RESOLVED, any words or disclosures shall be clearly legible and, if televised or displayed electronically, shall be displayed for a sufficient time to enable the viewer to easily see and fully read the disclosure or disclaimer and spoken disclosures shall be plainly audible and clearly intelligible and that “this is an advertisement” be included in all medical lawsuit advertisements;

BE IT FURTHER RESOLVED, an advertisement for legal services soliciting clients who may allege an injury from a prescription drug approved by the U.S. Food and Drug Administration shall include the following warning: “Do not stop taking a prescribed medication without first consulting with your doctor.  Discontinuing a prescribed medication without your doctors’ advice can result in injury (or death)”;

BE IT FURTHER RESOLVED, an advertisement for a lawsuit soliciting clients who may allege an injury from a prescription drug or medical device approved by the U.S. Food and Drug Administration shall disclose that the drug or medical device remains approved by the U.S. Food and Drug Administration unless the product has been recalled or withdrawn;

BE IT FURTHER RESOLVED, this provision shall not be construed to apply to the use or disclosure of protected health information to an individual’s legal representative in the course of any judicial or administrative proceeding, or as otherwise permitted or required by law; and

BE IT FINALLY RESOLVED, that the NBCSL send a copy of this resolution to the President of the United States, the Vice President of the United States, members of Congress, and other federal and state government officials as appropriate.

• SPONSOR: Representative Barbara Ballard (KS)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ON INCREASING ACCESS TO FRESH FRUITS AND VEGETABLES BY ENHANCING THE BENEFITS OF SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) RECIPIENTS AND CREATING INCENTIVES

WHEREAS, the National Black Caucus of State Legislators (NBCSL) recognizes that our constituents face a growing burden of largely preventable chronic illnesses, such as heart disease, stroke, obesity, and diabetes;

WHEREAS, the Supplemental Nutrition Assistance Program (SNAP), the largest anti-hunger program in the United States, provides critical food assistance to nearly 41 million low-income Americans;

WHEREAS, African-Americans are disproportionately affected by food insecurity;

WHEREAS, the food insecurity rate among African-American, non-Hispanic households is more than double that of White, non-Hispanic households;

WHEREAS, SNAP helps households improve food security, reducing the number of people who skip meals because they don’t have the money or resources to buy enough food;

WHEREAS, a Center on Budget and Policy Priorities analysis using the government’s Supplemental Poverty Measure (which counts SNAP as income) and correcting for underreporting in government surveys found that SNAP kept 8.4 million people out of poverty in 2015, including 3.8 million children;

WHEREAS, SNAP plays an important role in boosting the economy of low-income communities, with every $5 in new SNAP benefits generating $9 for the local economy. Additionally, an increase of $1 billion in SNAP expenditures is estimated to increase economic activity (GDP) by $1.79 billion;

WHEREAS, one study has concluded that more than 40 million Americans who rely on a government nutrition program face risks for major health problems because the program lacks nutrition standards;

WHEREAS, the Food, Nutrition, and Conservation Act of 2008 authorized the Healthy Incentives Pilot (HIP) was designed to test the impact of incentivizing fruit and vegetable purchases among a small group of SNAP recipients;

WHEREAS, according to a HIP study, households participating in Healthy Incentives Projects reported spending $78.17 each month on all fruits and vegetables, $6.15 more than households that did not participate in the program;

WHEREAS, two-thirds of HIP households said they bought larger amounts and a greater variety of fruits and vegetables because of the HIP. Additionally, these households ate more fruits and vegetables; and

WHEREAS, SNAP recipients who were given incentives to buy more fruits and vegetables ate almost a quarter of a cup more of fruits and vegetables per day.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) recognizes the importance of SNAP in increasing access to healthy food in vulnerable communities;

BE IT FURTHER RESOLVED, that the NBCSL urges the program to offer incentives for purchasing fruits and vegetables and create evaluations to assess elements such as the impact on consumer purchasing, availability, stigma and retailer implementation;

BE IT FURTHER RESOLVED, that the NBCSL recommends supporting state and local policies that create enhanced SNAP education and fund or expand SNAP incentive programs;

BE IT FURTHER RESOLVED, that the NBCSL urges states and communities to pass policies that increase targeted projects for SNAP authorized-retailer incentive programs for SNAP benefits when used on fruits and vegetables; and

BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, the Vice President of the United States, members of the United States House of Representatives and the United States Senate, U.S. Department of Agriculture and other federal and state government officials, as appropriate.

• SPONSOR: Representative Toni Rose (TX)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ON PATIENT OUT‐OF‐POCKET COSTS

WHEREAS, the National Black Caucus of State Legislators (NBCSL) acknowledged the importance of health care costs for their constituents by ratifying policy resolutions on reasonable out‐of‐pocket (OOP) health care expenses (HHS‐15‐31) and improving patient affordability of medicines (HHS‐18‐24);

WHEREAS, health plan sponsors—employers and health plans—are increasing the financial burden on patients by requiring them to pay a growing share of out‐of‐pocket costs in the form of premiums, deductibles, and copayments and out‐of‐pocket costs for patients can exceed 30% of the cost of primary care, specialist visits, and some medications, while average deductibles have increased by 150% over the past five years;

WHEREAS, employers are directing more workers into high deductible health plans (HDHPs), which force enrollees to pay high OOP costs until their deductible is met;

WHEREAS, the percentage of workers enrolled in a HDHP went from 5% in 2007 to 17% in 2011 to 28% in 2017. The average deductible for a HDHP enrollee was $2,300 for single coverage and $4,527 for family coverage in 2017;

WHEREAS, many patients have no choice but to enroll in a HDHP. In 2017, 30% of covered workers worked for employers that only offered a HDHP, compared to 23% in 2015;

WHEREAS, many patients have access to copay cards to help them afford their OOP costs for some prescription medications, health insurers are implementing policies that prevent this spending from counting toward a patient’s deductible, which can dramatically slow a patient’s ability to meet his or her deductible;

WHEREAS, a patient’s OOP costs have a direct impact on adherence to prescription drug treatment, and a patient may choose to not start or to abandon therapy if the OOP cost is too high, this can have a negative impact on a patient’s health and may result in more downstream costs to the health care system;

WHEREAS, research has found that doubling copays reduced patients’ adherence to prescribed medicine by 25‐45%, and increased emergency room visits and hospitalizations, which drives up health care costs;

WHEREAS, the costs and negative health consequences associated with lack of prescription adherence can be avoided by lowering patient’s OOP costs;

WHEREAS, when monthly OOP costs can be kept below $250 for a specialty drug prescription, patients are less likely to abandon therapy; and

WHEREAS, in 2017, four in 10 American adults could not meet an unexpected expense of $400 without borrowing money, selling something, or carrying a balance on a credit card, and thus, since patients struggle with high OOP costs.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) recognizes it is critical that state policies protect the ability of patients to use co‐pay assistance programs, including co‐pay cards, to help cover OOP expenses and help ensure a patient’s ability to access life‐saving therapies;

BE IT FURTHER RESOLVED, states should oppose policies that put limitations on the ability of patients to utilize co‐pay assistance.  Further, states should implement policies that limit insurer efforts to increase patient OOP burden, and support policies that lessen patient OOP costs including policies that require insurers to offer copay only insurance plans, and/or policies that put a cap on patient OOP costs; and

BE IT FINALLY RESOLVED, that the NBCSL send a copy of this resolution to the President of the United States, the Vice President of the United States, members of Congress, and other federal and state government officials as appropriate.

• SPONSOR: Senator Mattie Hunter (IL)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ON TELEPHONE CPR

WHEREAS, the National Black Caucus of State Legislators (NBCSL) recognizes that our constituents face a growing burden of cardiovascular disease which may cause cardiac arrest;

WHEREAS, each year more than 350,000 sudden cardiac arrest (SCA) events occur in the United States in an out-of-hospital environment;

WHEREAS, blacks are more likely to experience sudden cardiac arrest, and at a much younger age, than whites;

WHEREAS, bystander CPR is performed in less than half of all cardiac arrests, leading to survival rates that vary by as much as 500% regionally in the United States;

WHEREAS, for every minute without CPR, chances of survival drop by 10%;

WHEREAS, bystander CPR for witnessed out of hospital cardiac arrest is believed to strongly influence survival to hospital discharge;

WHEREAS, people who live in African-American, Hispanic, and lower-income neighborhoods are more likely than others to die from a cardiac arrest, and African-Americans and Hispanic cardiac arrest victims are also 30% less likely to have someone stop and perform CPR;

WHEREAS, currently only three percent of 9-1-1 medical responders provide compression-only CPR instructions, but telephone CPR (T-CPR) is associated with a 32% increase in survival to hospital discharge;

WHEREAS, T-CPR is the delivery by trained 911 telecommunications professionals of high-quality CPR instruction for acute events requiring CPR, including but not limited to, out-of-hospital cardiac arrests (OHCA); and

WHEREAS, T-CPR will strengthen the chain of survival and give professional responders a better chance of success when they arrive on the scene of a cardiac arrest.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) recognizes that Telephone CPR saves lives from cardiac arrest and should be a standard of care for every emergency dispatch center in the United States;

BE IT FURTHER RESOLVED, that the NBCSL recommends supporting state and local policies that require training for 911 dispatchers to be trained in providing telephone CPR;

BE IT FURTHER RESOLVED, that the NBCSL urges states and communities to pass legislation that requires all 911 telecommunications professionals that provide dispatch for emergency medical conditions be trained in the delivery of high-quality telephone CPR; and

BE IT FINALLY RESOLVED, that the NBCSL send a copy of this resolution to the President of the United States, the Vice President of the United States, members of Congress, and other federal and state government officials as appropriate.

• SPONSOR: Senator Troy Carter (LA)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ON PROSTATE CANCER AWARENESS

WHEREAS, in 2018 there are expected to be about 164,690 new cases of prostate cancer and about 29,430 deaths from prostate cancer in the United States;

WHEREAS, prostate cancer is a disease that disproportionately affects men with a family history of this disease (particularly brother and/or father) and as they advance in age;

WHEREAS, African-American men are at an increased risk of developing prostate cancer compared to white men and other men of color. One in six African American men will develop prostate cancer in his lifetime;

WHEREAS, African-American men are 1.7 times more likely to be diagnosed with—and 2.3 times more likely to die from—prostate cancer than white men. African American men are also slightly more likely than white men to be diagnosed with advanced stages of the disease;

WHEREAS, race, age and family history present a triple risk for older African Americans;

WHEREAS, finding prostate cancer when it is still at an early stage offers the best hope for effective treatment and potentially living cancer free;

WHEREAS, if the disease progresses to metastatic, the prognosis is poor with median survival of about 3 years;

WHEREAS, improved awareness of prostate cancer, understanding of increased risks for developing it, as well as access to recent medical advances that may extend the time a patient lives without their cancer spreading are important to improve patient outcomes; and

WHEREAS, the National Black Caucus of State Legislators (NBCSL) has called for increased funding and outreach in resolution HHS-08-23 “To Adopt Additional Funds for Education, Awareness, Outreach, and Early Detection for Prostate Cancer.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) calls on states to take action on prostate cancer awareness;

BE IT FURTHER RESOLVED, that the NBCSL call on states to encourage culturally-competent outreach efforts to educate and inform communities of color on the importance of early detection;

BE IT FURTHER RESOLVED, that the NBCSL calls on states to encourage African-American men to participate in clinical trials and for clinical trials to actively recruit African-American men; and

BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, Vice President of the United States, members of the United States House of Representatives and the United States Senate, and other federal and state government officials as appropriate.

• SPONSOR: Representative Toni Rose (TX) and Representative Sharon Beasley-Teague (GA)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION TO ENSURE THE USE OF APPROPRIATELY SAFEGUARDED VALUE FRAMEWORKS IN HEALTHCARE

WHEREAS, the United States spends substantially more on health care services than any other country in the world but has poorer healthcare outcomes per dollar;

WHEREAS, according to the Centers for Medicaid and Medicare Services, in 2016, Hospital Care accounted for 32 percent of national health expenditures, Physician and Clinical Services accounted for 20 percent of national health expenditures, and pharmaceutical accounted for 10 percent of national health care expenditures;

WHEREAS, Americans spends less on prescription drugs as a percentage of overall health care spending than the majority of developed nations;

WHEREAS, many health conditions from mental health to cancer are ripe for development of more effective drug therapies, innovation must be incentivized to bring these new breakthrough drugs to market;

WHEREAS, while medicines bring good value to the health care system and close to 90 percent of medicines dispensed today are generics, newer therapies that reflect advances in innovation may have a higher price;

WHEREAS, stakeholders across the healthcare ecosystem are looking for new ways to define and estimate the value of health care interventions – especially medicines – as payment models shift from volume to value;

WHEREAS, different patients respond to drug treatments differently, and insurers are often averse to the risk of paying for new high-cost therapies when outcomes are not guaranteed, and members frequently change health plans;

WHEREAS, traditional reimbursement models and restrictive benefit designs can threaten patient access to new therapies, which can have a direct impact on a patient’s health and generate more downstream costs to the health care system;

WHEREAS, the consensus of the health care community is that the health care system must move from simply paying for services to paying for health outcomes;

WHEREAS, several insurers and drug manufacturers are interested in and are actively working on value-based reimbursement models that pay for better outcomes instead of just the dispensed therapy;

WHEREAS, in determining the quality of an outcome, different stakeholders, such as patients and insurers, view the effectiveness of medicines differently;

WHEREAS, well-designed value frameworks that recognize the total value that a medicine brings to patients, caregivers and society, over the long-term can facilitate informed, shared decision-making and improve the quality and efficiency of the health care system;

WHEREAS, there are no set criteria for determining the value of medicines, therefore, frameworks often use entirely different factors when determining a treatment’s value;

WHEREAS, “value frameworks” have emerged in the United States as a direct response to the shift towards value-based payment models;

WHEREAS, the stated purpose of value frameworks is to combine clinical and economic analyses to evaluate whether the benefits of medications align with their cost, different stakeholders, such as patients and insurers, view the effectiveness of medicines differently;

WHEREAS, well-designed value frameworks that recognize the total value that a medicine brings to patients, caregivers and society, over the long-term can facilitate informed, shared decision-making and improve the quality and efficiency of the health care system;

WHEREAS, there are multiple criteria for determining the value of medicines, therefore, frameworks often use entirely different factors when determining a treatment’s value;

WHEREAS, value frameworks should recognize that the patient is the ultimate stakeholder in the health care system or that a treatment’s benefits changes over time and therefore must consider value from both a short- and long-term perspective;

WHEREAS, certain value frameworks determine a drug’s value by estimating the value of human life using a metric known as cost per quality-adjusted life year (QALY), which measure the amount of time patients live after receiving treatment and the quality of the patient’s health during that treatment;

WHEREAS, the use of the QALY-based frameworks is specifically prohibited by federal legislation for establishing what type of health care is cost effective or recommended, including for Medicare coverage decisions; and

WHEREAS, while correctly structured value-based arrangements are one solution that can lead to greater care and efficiencies for all, there are statutory and regulatory constraints that threaten the ability of drug manufacturers to enter into appropriately safeguarded value-based payment arrangements.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL) urges states or insurers to consider value frameworks to make clinical or coverage decisions, in addition to the data provided by QALY-based frameworks;

BE IT FURTHER RESOLVED, that the NBCSL encourages the appropriate use of value frameworks that lower health care cost and improve health outcomes for patients, as guidance for therapies and insurance coverage, instead of being the sole dictator;

BE IT FURTHER RESOLVED, that the NBCSL supports incorporating the patient voice in evaluating a treatment’s value, considering not only data from clinical trials but also the patient experience including the impact of an intervention on their quality of life, the convenience of intervention, and its impact on overall well-being;

BE IT FURTHER RESOLVED, that the NBCSL recommends that value frameworks appropriately weigh the clinical, economic and societal benefit that a medicine provides;

BE IT FURTHER RESOLVED, that the NBCSL recommends that value frameworks reflect perspectives from all relevant stakeholders through a transparent public review and commentary process;

BE IT FURTHER RESOLVED, that the NBCSL opposes value frameworks or value-based arrangements that lack any of the patient, caregiver, social, participatory and transparency safeguards and protections outlined in this Resolution, underscoring that other frameworks, such as QALY-based frameworks, should not be used by states or insurers as the sole or dominant tool used to make clinical or coverage decisions, particularly pricing, co-pay, deductible or other payment determinations; and

BE IT FINALLY RESOLVED, that the NBCSL send a copy of this resolution to the President of the United States, the Vice President of the United States, members of Congress, and other federal and state government officials as appropriate.

• SPONSOR(S): Representative Barbara Ballard (KS) and Representative Calvin Smyre (GA)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President

A RESOLUTION ENCOURAGING STATES TO SCREEN NEWBORNS FOR ALL DISORDERS LISTED ON THE RECOMMENDED UNIFORM SCREENING PANEL

WHEREAS, newborn screening panels effectively detect many disorders in children at an early age that would not otherwise be diagnosed;

WHEREAS, the effects of these disorders can be reduced or eliminated through early therapeutic interventions;

WHEREAS, states have discretion as to which disorders to include in their newborn screening panels;

WHEREAS, the Advisory Committee on Heritable Disorders in Newborns and Children uses its expertise and resources to create a Recommended Uniform Screening Panel (RUSP) which details 35 disorders that ought to be included in newborn screening panels;

WHEREAS, only two states currently test for all 35 disorders in the RUSP;

WHEREAS, expansion of universal newborn screening panels in states helps reduce health disparities based on income, location, education, and race or ethnicity; and

WHEREAS, in 48 states a child may be born today with a disorder that could be diagnosed and treated, but often is allowed to linger today due to state inaction.

THEREFORE BE IT RESOLVED, that the National Black Caucus of State Legislators (NBCSL), urges all states to expand statewide screening of newborns to include screening for any disorder currently listed in the RUSP as soon as practicable, but no later than 2020;

BE IT FURTHER RESOLVED, that the NBCSL urges all states to expand statewide screening of newborns to include screening for any disorder that is detectable in blood samples as soon as practicable, but no later than two years after the disease is adopted by the federal RUSP;

BE IT FURTHER RESOLVED, that the NBCSL urges all states to add, as soon as practicable, to their newborn screening panels any disorders that are detectable in blood samples which have high mortality rates or gravely affect one’s quality of life and can be treated or cured when caught shortly after birth; and

BE IT FINALLY RESOLVED, that a copy of this resolution be transmitted to the President of the United States, the Vice- President of the United States, members of the U.S. Congress, and other federal and state officials as appropriate.

• SPONSOR(S): Representative Gregory Porter (IN) and Representative Calvin Smyre (GA)
• Committee of Jurisdiction: Health and Human Services Policy Committee
• Certified by Committee Chair(s): Representative John King (SC) and Representative Toni Rose (TX)
• Ratified in Plenary Session: Ratification Date is November 30, 2018
• Ratification is certified by: Representative Gregory W. Porter (IN), President