Friday, May 1, 2015
HHS Budget Bills Head to Conference Committee
Covering the second largest part of the state’s budget, the HHS omnibus funding proposals have passed both the House and Senate, though in markedly different forms. The differences will be negotiated in a 10-member conference committee of members of both the House and Senate. The differences between the two bills are large, with a difference of spending of more than $1.4 billion, as well as dozens of provisions included in one package and not the other.
The Senate acted first when it passed SF 1458 authored by Sen. Tony Lourey (DFL - Kerrick) on April 29. Providing $13.1 billion in funding for the next biennium, the Senate bill is 454 pages long. Among the provisions included in the bill is reform of the prior authorization process, a bill authored by Sen. Melisa Franzen, led by the MMA, and supported by the MAFP, other medical specialties, and dozens of patient advocacy groups. The Senate bill also includes a 1% increase in primary care physician reimbursement in the MA and MinnesotaCare programs.
Also of note in the Senate bill are changes to MNsure, including repeal of the existing board of directors and moving MNsure to the executive branch where the director would be a political appointee of the Governor. Supporters argue the move will provide more accountability than an unelected board. Also included in the Senate package are new uses for the All Payer Claims Database (APCD), funding for multiple mental health programs, and funding to reduce the incidence of fetal alcohol syndrome.
The House HHS Omnibus funding bill is authored by Rep. Matt Dean (R – Dellwood). It (HF 1638) passed the House floor shortly after 1:00 AM on the morning of April 29 following a debate of more than seven hours. The centerpiece of the proposal is a repeal of MinnesotaCare, the health insurance program for low-income Minnesotans who earn too much to qualify for Medical Assistance. MinnesotaCare enrollees would instead be moved into MNsure, the state’s health insurance exchange, where they would be eligible for federal and state tax credits to assist in the purchase of enhanced, silver-level plans. The author and House Republicans argued that MinnesotaCare is too expensive and unsustainable into the future. At the same time, the bill also sets MNsure on a path to repeal, ultimately moving all enrollees to the federal health insurance exchange. As part of the move away from MinnesotaCare, the House Tax bill (see below) accelerates the repeal of the provider tax one year to Dec. 31, 2018.
Opponents of the bill argue that the premiums and out-of-pocket expenses for plans through MNsure will be so high as to lead many families to either purchase high-deductible health plans that provide poor coverage or forgo insurance entirely. Others, including the MMA and other physicians’ groups, have been highly critical of the bill’s transfer of more than $600 million of General Fund obligations to the Health Care Access Fund.
Just as with the Senate companion, the House bill contains dozens of different provisions, including cuts to the Department of Health & Human Services and Minnesota Department of Health’s administrative budgets, competitive bidding requirements for PMAP providers, and investments in a number of new and existing mental health services and initiatives, and child protective services. Of note, the House file does not include the prior authorization reform language that is embedded in the Senate bill, and it also eliminates funding for the State Health Improvement Program (SHIP), a means of investing in local public health programming. The House version of the bill also includes expanded authority for pharmacists to administer vaccines, something not included in the Senate bill. And finally, only the House version of the bill includes funding for community groups to support promotion of advanced planning and “living wills” within families, an effort led by the Twin Cities Medical Society (TCMS).
The conference committee is expected to begin meeting early next week.
Physician Compact Receives Unanimous Vote
The effort to enroll Minnesota in a soon-to-be established compact of states intended to ease the process of licensure for physicians who wish to be licensed in multiple states took a leap forward on April 30th when it passed the Senate on a 59 to 0 margin.
Under the bill, SF 253, sponsored by Sen. Kathy Sheran (DFL - Mankato), Minnesota would participate in a newly created interstate compact that would expedite the process by which physicians who practice in multiple states can be licensed. Completely voluntarily for physicians, the commission established under the bill would serve as a "clearinghouse" that would ease the burden of seeking licensure in multiple states. The commission only becomes functional once passed by at least seven states. To date six states have passed the identical bill and it has been introduced in 13 state legislatures.
The bill has seen little organized opposition in the state. Supporters have included the Board of Medical Practice, the MMA, the Minnesota Hospital Association, Mayo Clinic, Allina Health, Sanford Health, Essentia Health, Children’s Hospitals and Clinics, Gillette Specialty Healthcare, and Gundersen Health. The House bill, HF 321, is authored by Rep. Tara Mack (R - Apple Valley) and is expected to be heard on the House floor in the coming weeks.
Higher Ed Bills Invest in Medical Education & Training
The package of funding proposals for the University of Minnesota and MNSCU making way through the legislative process include a number of notable pieces that support medical education and training. The Senate's funding package,SF 5, authored by Sen. Terri Bonoff (DFL - Minnetonka) passed the Senate on April 20. The House proposal, authored by Rep. Bud Nornes (R - Fergus Falls), had cleared the full House on April 27. Given significant differences in the bills, a final package will be negotiated by a conference committee made up of members from both the House and Senate.
Both versions of the higher education bills contain funding for the residency program at United Family Medicine, though the House funds the program at a slightly higher level of $500,000 in both years of the next biennium. Both proposals also fund graduate family medical education programs at HCMC at $645,000 in both 2016 and 2017. The bills also include provisions to fund research into biotechnology and medical genomics via a joint Mayo Clinic and University of Minnesota research partnership. The Senate includes provisions not contained in the House version, including family medicine residency programs at the St. Cloud Hospital as well as funding for Alzheimer's disease and traumatic brain injury research. In a novel section of the Senate bill, the University of Minnesota is authorized to refinance the bonds for the construction of TCF Bank Stadium, with the savings earmarked for the Medical School and Academic Health Center.
The Senate bill also contains language requiring monthly reports by the University to the Higher Education Committees in the House and Senate regarding the Board of Regents progress in developing and implementing a plan to conduct human subject research at the University. The U of M came under fierce scrutiny of the handling of the suicide of a subject participating in a psychiatric drug trial in 2004. The case was the subject of a highly critical report from the Office of the Legislative Auditor who stated that the case involves “serious ethical issues and numerous conflicts of interest(s)” between the University and drug manufacturers.
Tobacco Provisions Included in Tax Bill
Unveiled in a committee hearing April 23, the House Omnibus Tax bill contains a number of notable provisions related to tobacco taxation totaling almost $80 million. Authored by House Tax Committee Chair Rep. Greg Davids (R - Preston),HF 848 repeals a piece of the landmark 2013 tobacco tax bill that in addition to raising the tax on a pack of cigarettes by $1.60 included an automatic annual inflationary increase. The annul inflator would be repealed by the House bill. Also included in the House tax bill is language to alter the way e-cigarettes are taxed. Currently law taxes e-cigarettes at 95% of the wholesale price. Under the new law, taxation would be based upon the volume of liquid nicotine. The provision is largely seen as a boon to the big tobacco companies that have come to dominate the e-cigarette market at the expense of smaller independent "vape shops." Anti-tobacco groups have opposed the provision on the grounds that the change would likely make those e-cigarette devices most accessible to minors cheaper.
The only tobacco related provision in the Senate's version of the tax bill is language closing the loophole on bulk tubs of moist tobacco. Some manufacturers have begun selling large tins of chewing tobacco that exploit a loophole on state tax law making the product cheaper. The Senate bill is authored by Sen. Rod Skoe (DFL - Clearbrook), the chair of the Senate’s Tax Committee.
Not included in either proposal is any change in how premium cigars are taxed. Under proposals introduced and considered in both bodies was a dramatic lowering of the rate of taxation on cigars that cost more than three dollars.
"Right to Try" Bill Handily Passes Senate
A bill that would allow terminal patients access to pharmaceutical drugs, biological products, and devices that have not completed FDA trials handily passed the Senate on April 21 by a margin of 60 to 4.
The bill, SF 100, addresses patients with "a condition or illness which, to a reasonable degree of medical probability, is not considered reversible and even with the administration of current FDA-approved and available treatments and the administration of life-sustaining procedures will soon result in death." The bill, authored by Sen. Brandon Petersen (R - Andover), does not mandate that a pharmaceutical or device manufacturer make the products available. The bill does require that the patient give written informed consent, as well as to receive a prescription or recommendation from a physician, before they’d be eligible.
The House companion, carried by Rep. Nick Zerwas (R - Elk River), is scheduled to be considered on the House floor on May 1.
Provider Tax Repeal Accelerated In House Tax Bill
The House of Representatives approved a package of tax cuts totaling more than $2 billion on April 29. In addition to cuts in various business taxes, agriculture-related taxes, and other elements, the bill also hastens the repeal of the provider tax from December 31, 2019 to December 31, 2018. The accelerated repeal is closely linked to the proposal to repeal MinnesotaCare, as the provider tax serves is the principle funding source for the program.
The Senate’s tax bill has not yet been considered on the floor and does not contain the accelerated repeal provision. Given the difference between the two tax bills, a conference committee will be appointed to negotiate the differences. No proposals have been put forward during the session to extend the provider tax or rescind the repeal.
Trisomy Awareness Bill Passes the Senate
A bill that would require those who administer prenatal or postnatal tests to give patients certain information if the test shows the presence of a trisomy condition easily passed the floor on April 30 by a margin of 58 to 1. Under thelegislation, authored by Sen. John Hoffman (DFL – Champlin), physicians or others who administrator such tests would be required to direct patients to information maintained on the website of the Minnesota Department of Health (MDH). MDH would be required to post up-to-date and evidence-based information about trisomy conditions that has been reviewed by medical experts and national trisomy organizations, including life expectancy, treatment options, and links to support and advocacy groups.
The House companion to the bill, HF 439 (Rep. Kathy Lohmer, R – Stillwater), has not yet been scheduled for consideration on the House floor, though the language of the bill has been included in the House’s version of the HHS Finance package.