Wednesday, April 1, 2015
Easter/Passover Break Marks Session's Midpoint
Friday, March 27th began a 10-day break for the Easter and Passover holidays following a scramble of late nights of committee meetings to pass bills before the second deadline. The annual break represents an unofficial “mid-point” in the session and marks the coming of budget hearings and negotiations. With the passage of the second policy committee deadline on March 27th, much of the work of policy committees has been completed, and the action will shift to the committees with jurisdiction on spending and taxing issues.
With the break, many legislators will be back in their districts and holding ‘town hall’ meetings with constituents. It’s a terrific opportunity to visit your elected official to share with them what issues are important to you. Legislators want to hear from their local physicians and these visits can be very impactful.
Legislators return to St. Paul on Tuesday, April 7, for the final sprint to finish their work before the May 18 required adjournment date.
Budget Targets Announced by House, Senate Leaders
The work of setting the two-year state budget for the state began in earnest last week when both the House Republicans and Senate Democrats announced their budget targets. These numbers set overall spending for both the entire state government and within individual areas of state government (e.g. K-12 education, HHS, transportation, etc.). While the Senate targets are largely in line with the figures proposed by Governor Dayton in mid-March, the House Republican targets are very different.
Presented in a press conference by Speaker of the House Kurt Daudt (R – Crown) and Ways & Means Committee Chair Rep. Jim Knoblach (R – St. Cloud), the Republicans propose overall state spending of just under $40 billion for the 2016-2017 biennium, with an additional $2 billion in unspecified tax cuts. Included in their spending numbers is $11.6 billion in the HHS budget. Republican leaders argued that the HHS number represents an increase of more than $400 million over 2014-2015 levels, while their DFL opponents noted that the figure will require $1.1 billion of cuts from the projected HHS spending for 2016-2017 that is included in current law.
Later in the week, Senate Democrats then put forward their budget targets. Their budget more closely matches that put forward by Governor Dayton earlier in the year. Their budget provides for biennial spending of $42.7 billion, including an additional $341 million in HHS funding above current projections. Senate Majority Leader Tom Bakk (DFL – Cook) also noted in his budget announcement that increased funding for loan forgiveness for rural physicians remains a high priority.
The finance committees in both bodies will begin to craft their budgets upon their return from the Easter/Passover break. Given the expected differences between the two approaches, Senate and House leaders – likely in conjunction with the Governor and his top officials – the final action will require conference committees and behind-the-scenes negotiations.
Future of MinnesotaCare
One of the central questions in the HHS funding debate will be the future of MinnesotaCare. During the last legislative session, the Legislature amended MinnesotaCare to qualify as a “Basic Health Plan” (BHP) as allowed under the ACA. Minnesota is the only state in the country offering a BHP. MinnesotaCare currently provides robust health coverage to enrollees with very limited out-of-pocket expenses. Critics have suggested that the program as constructed is too expensive and not sustainable.
One of those critics, Rep. Matt Dean (R – Dellwood), the chair of the House HHS Finance Committee, has proposed an alternative. Under Rep. Dean’s bill, HF 1665, the current MinnesotaCare program would be repealed and replaced by a new system dubbed “MinnesotaCare II.” Enrollees would be given state subsidies and required to purchase silver-level health plans through MnSure, the state’s health insurance exchange. The additional subsidies would increase the coverage so as to reduce the expected co-pays and deductibles.
The advantages of MinnesotaCare II would be that payments to physicians and other providers would be at commercial rates instead of the extremely low MA rate, and it would reduce pressure on the state’s 2% provider tax, which is scheduled to be repealed in 2019. The concern is that it’s not yet clear what these health plans would look like in terms of out-of-pocket expenses, copays, or deductibles, and whether the projected higher cost-sharing requirements will be too burdensome for low-income Minnesotans to afford. Senate leaders and Governor Dayton’s office have indicated that they are strongly opposed to any proposal that dismantles MinnesotaCare in its current form.
Prior Authorization Reform Misses Committee Deadline
The MMA-led effort to reform the laws governing prior authorization took a blow recently when the House HHS Reform Committee declined to hear the bill before the Legislature’s second policy committee deadline. While the bill,SF 934, had passed the necessary policy committee in the Senate with little opposition from legislators, opponents – particularly the health plans and pharmacy benefit managers (PBMs) successfully blocked the bill’s consideration in the House.
While certainly a setback, the door has not yet closed on moving the contents of the bill forward this year. The authors of the legislation, Sen. Melisa Franzen (DFL – Edina) and Rep. Tony Albright (R – Prior Lake), have expressed interest in pursuing other mechanisms to enact some elements of the bill. It’s possible that the bill could be included in a larger omnibus package of HHS finance-related provisions, and it’s possible that pieces could be amended into other bills. This remains a priority issue for the more than 40 organizations that support its passage. Those groups are all listed on the fixPAnow.com website.
Bill to Allow More Immunizations by Pharmacists Moves Forward
A bill to expand the authority of pharmacists to administer vaccines was considered in the HHS policy committees in both bodies in recent weeks. The bill,SF 1765 authored by Sen. Julie Rosen (R – Vernon Center) and HF 1659, authored by Rep. Roz Peterson (R – Lakeville) are being promoted by the Board of Pharmacy. The primary focus of the bill is a Board of Pharmacy proposal to alter the law that governs how many pharmacy technicians a pharmacist may oversee.
In addition, the bill also changes pharmacists’ authority to give immunizations. Current law allows pharmacists to administer influenza vaccines to patients ten years and older and all other vaccines to those patients 18 and older. As introduced, the bill reduced the ages at which pharmacists may give vaccinations, lowering the influenza threshold to six and to 13 for other vaccines. After concerns were raised by physician’s groups (including the MMA, MNAAP, and MAFP) and the Minnesota Department of Health (MDH), the Senate bill was amended to limit the authority for pharmacists, for immunizations other than flu shots, to only administer booster immunizations or to complete a series of shots initiated by a physician. For example, pharmacists would be allowed to administer the second or third shot in an HPV series, but not give the first immunization. The House bill does not contain this provision, so the difference will be subject to negotiation or a conference committee should the bills pass both bodies.
The bill also strengthens the law that requires pharmacists to report immunizations either to the Minnesota Immunization Information Connection (MIIC) or to the patient’s primary care physician. Under the bill, the pharmacist is required to utilize the MIIC to assess the immunization status of all individuals prior to administering a vaccine, and must report all immunizations to the MIIC.
Legislative Focus on Mental Health Continues
The Legislature continues to have a strong focus on issues related to mental health this year as many bills on this subject have been introduced and received hearings. A number of legislators including key committee chairs, as well as Lucinda Jesson, Commissioner of the Minnesota Department of Human Services, attended a press event held by the National Association on Mental Illness (NAMI). While a number of mental health policy bills continue to move, much of the work of supporting those with mental illness and the providers who care for them will be determined as the HHS budgets are crafted in the coming weeks.
Notable mental health bills include:
- HF1201/SF 1152 Introduced by Rep. Joe Schomacker (R – Luverne) and Sen. Kent Eken (DFL – Twin Valley), this would provide an additional $1.5 million in funding for the state’s text message-based system of suicide prevention. The program got its start in 2014.
- HF 1209/SF 1311 Introduced by Rep. Bob Barrett (R – Lindstrom) and Sen. Kathy Sheran (DFL – Mankato), this provides additional funding for “mental health first aid” training to teachers, social service personnel, law enforcement, and others who come into contact with children with mental illnesses. The bill also requires better and timelier reporting of suicide-related data, as well as requiring training of teachers in suicide prevention.
- HF 1062/SF 717 Introduced by Rep. Tony Albright (R – Prior Lake) and Sen. Chris Eaton (DFL – Brooklyn Center), this bill adds coverage of mental health crisis services to the list of essential health benefits under state law. This same proposal would fund the creation of 24-hour consultation services for mobile crisis teams that are serving people who are experiencing a mental health crisis.
- HF 1155/SF 1078 Introduced by Rep. Nick Zerwas (R – Elk River) and Sen. Bobby Joe Champion (DFL – Minneapolis), this bill allows easier sharing of medical records within the welfare system. Under the bill, a patient could grant lifetime consent for the sharing of medical records between health care providers and social services. The chief advocate for the bill is HCMC, as they believe it will better allow care to be coordinated for the homeless and transient population it serves.
One other bill related to mental health services has drawn some controversy. The bill, SF 141 (Sen. Barb Goodwin; DFL – Columbia Heights) and HF 240 (Rep. Nick Zerwas; R – Elk River), would establish a program where low-level criminal suspects with mental illness are diverted from jail to mental health treatment centers. The bills have been supported by many in the law enforcement community, though some mental health advocates (including NAMI-MN) have expressed concern. While supporting the concept and goal of diversion, these advocates argue the bill would divert scarce resources away from treatment. The Senate bill was passed out of the required policy committees though the House companion has not received any hearings.
Physician Assisted Suicide Bill Receives Informational Hearing
A bill to allow physician-assisted suicide was introduced in both the House and Senate, though the authors quickly acknowledge their intent was not to pursue them this year but use the bills to start a broader, statewide conversation about the issues of patient decision-making and autonomy at the end of life.
The Senate took up SF 1880, authored by Chris Eaton (DFL - Brooklyn Center) in an informational hearing on March 23. Senator Eaton was joined by David Grube, MD, an Oregon family physician and the National Medical Director for Compassion & Choices. Also speaking in support was a woman whose parents had extended, difficult deaths who had stated their interest in assisted suicide. No official action was taken at the hearing, and no hearings are anticipated for the House bill, authored by Rep. Mike Freiberg (DFL - Golden Valley).
Under the bill, terminally ill patients would be allowed to request from their physician medication intended to aid in hastening death. The bill lays out a number of requirements that must be included in the request, including the number and type of witnesses to a patient's request, as well as multiple statements of intent made by the patient over the course of at least 15 days. The bill further specifies the role of attending physicians, including a requirement that they inform the patient of the prognosis, make a determination of competency, provide extensive documentation in the patient's medical record regarding the patient's wishes, and other requirements. The bill requires patients to "self-administer" the lethal medications. The bill is modeled after Oregon's assisted suicide legislation, in place since 1998.
Tax on Premium Cigars Rolled Back Via Bill
The state's enhanced tax on "premium" cigars would be dramatically reduced underHF 1544, which was heard in the House Tax Committee on March 25. The bill is authored by Rep. Jim Nash (R - Waconia). The bill was held over for possible inclusion in an omnibus tax bill that will be unveiled later in the session. The Senate bill, carried by Sen. Dave Senjem (R - Rochester) is set for a hearing shortly after legislators return from the Easter/Passover break.
Under current law, hand-rolled cigars that have a wholesale cost of more than $2.00 and whose wrapper is entirely made of tobacco are defined as a "premium cigar." These items are taxed at 95% of the wholesale value, though is capped at $3.50. This bill would lower that cap to $.50.
A number of individuals testified in opposition, including Lisa Mattson, MD, an MMA member and Past President of Twin Cities Medical Society, arguing that making tobacco less expensive serves no public good. The bill is being sought by tobacco retailers and the Cigar Association of America.
Minnesota Poison Control System Funding Bill Considered
An effort to increase funding for the state’s poison control center moved forward at the Capitol in recent weeks. The bipartisan billsHF 364/SF 359, authored by Rep. Joe Hoppe (R – Chaska) and Sen. Melisa Franzen (DFL – Edina), have cleared the required policy committees. The bills ask for $800,000 in funding per year.
The Minnesota Poison Control System is mandated in state law though state funding has sometimes been erratic and federal grant funding has recently been reduced. Located at Hennepin County Medical Center (HCMC), officials there have recently announced that they can no longer provide the service to the entire state without additional funding support from the state. The poison control center fields an average of 132 calls every day, and last year received more than 48,000 calls. System officials shared that almost a quarter of the calls come from health care providers.
The chief proponent for the funding package has been HCMC, and dozens of other groups – including the MMA and MNAAP – have joined the coalition of supporters. The bill has cleared the policy deadline and may be included in the omnibus funding packages to be presented in the coming weeks.