Legislative Update

April 1, 2011

CALS Funding Slashed
The Senate Health and Human Services budget bill (SF 760, summarized below) eliminates all funding for the successful Comprehensive Advance Life Support (CALS) program.  This cuts $377,000 each year from the state’s general fund. While this is a fairly small amount of money, this is one of many cuts that eliminate small, but important programs in its attempt to find $1.6 billion of spending cuts in the health and human services area. 

CALS was developed by the MAFP to provide ongoing training to physicians and other health care providers outside the metropolitan area.  The program has been very successful, providing training opportunities throughout the state.  The state funding is used to keep the costs of the program affordable to participants receiving the needed training.  This training is crucial for practicing physicians, nurses, physician assistants, paramedics, and others to keep their skills up to date.

The CALS program is not cut in the House HHS budget bill so this will be one of many items to be negotiated between the House and Senate in conference committee.  Most believe the entire bill is still heading for a Governor’s veto because of the many provisions that are unacceptable to Governor Dayton.

Loan Forgiveness Programs Eliminated
In another blow to efforts to address Minnesota’s health care workforce shortages, SF 760 eliminates all funding for state loan forgiveness programs.  The Minnesota Office of Rural Health runs a number of loan forgiveness programs for physicians and other health care practitioners willing to practice in rural and underserved areas.  These programs are designed to encourage physicians to practice in underserved areas by paying loan costs of up to $20,000 per year, for each year of service, for up to four years.  The Senate’s budget bill saves the state nearly $1 million each year by eliminating these programs. 

In addition to targeting rural and underserved areas, some of the loan forgiveness programs also target physicians who choose primary care specialties.  Again, these address workforce shortages by making it more attractive to choose a primary care specialty. 

With the elimination of these programs, the state is stepping away from its commitment to ensure the training of health care providers needed to meet the needs throughout the state.  It is also failing to address the growing problem of medical school debt.

Attack on Newborn Screening & Minor Consent Laws
Legislation is moving in the Senate that would dramatically alter the state’s Newborn Screening Program, as well as virtually repeal the minor consent provisions within state law.  As of this writing, there is no House companion.

SF 1017, a bill sponsored by Senator David Hann (R – Eden Prairie) would alter the newborn screening program from an “opt-out” where all children are tested unless a parent affirmatively declines, to an “opt-in” program where parents have to affirmatively say “yes” to having their newborn tested.  Evidence shows that this change would dramatically reduce the number of newborns receiving the tests, impacting both the value and utility of the program in offering early diagnosis of dozens of diseases.  Additionally, the bill requires destruction of all the blood samples within 24 months and removes the state’s registry of heritable and congenital diseases detected by the screening program.  These changes would significantly reduce the research value of the program.

The MAFP has strongly supported the newborn screening laws in their current language.  The opposition to this law mostly comes from those who oppose the state having any medical data on citizens unless that person has specifically consented to the use of that data. 

In a separate section of the bill, the state’s minor consent provisions that have been in state law since the early 1970s are repealed.  This law allows minors to provide consent for treatment related to reproductive health, chemical dependency, and mental illness. Under the bill, the only minors who would be allowed to provide consent would be those who are victims of incest, physical abuse, or sexual abuse.  In those cases, the minor would have to go before a judge and get court approval for treatment.

The changes made by the bill would mean that a family physician would not be able to offer services to a minor for reproductive services, STDs, alcohol or chemical abuse, or mental illness without the consent of the parent or guardian.  For minors who believe they cannot talk to their parents about these issues, they would not be able to seek medical treatment.

The bill received its first hearing in the Senate Judiciary Committee on March 25.  Testifying in opposition to the legislation were a pediatrician from the Academy of Pediatrics, a representative from the March of Dimes and a physician from the Mayo Clinic.  The bill passed the Judiciary Committee with all Republicans in support and all Democrats in opposition, and was sent to the Senate HHS Committee.

The newborn screening language is also wholly contained within the Senate HHS Budget bill, SF 760 (see below).  The minor consent changes are not.  It is unclear whether the stand alone bill, SF 1017, will move forward this year.

House and Senate HHS Committees Mark-Up Omnibus Bills
The House HHS Finance Committee and the Senate HHS Committee spent all last week on their omnibus budget bills.  Hearing from over 90 witnesses in the House and 80 witnesses in the Senate, the committees “marked up” their bills on March 23 and 24. While the two bills differ greatly in approach, they both cut over $1.6 billion from the health and human services programs.  The Senate makes drastic spending cuts, while the House bill, described by its author Representative Abeler as a “work in progress,” relies largely on federal waivers to provide over $783 million in savings.  Both Gov. Dayton and DFL legislators were quick to complain about the devastation of the cuts and the lack of legitimate fiscal notes used to “cost out” various provisions in the bills.  They argued that they were unable to consider the merits of the bills without knowing the financial impact of the proposals they contain.

Here are brief overviews of the House and Senate bills:

The financial backbone of the House bill - close to three-quarters of the cuts - come in the form of four large ticket items that are long on savings, but short on details. Most of these cuts will require a waiver from the federal government to implement, but the Commissioner of Human Services testified that she did not think they would approve the federal waivers being requested.

1. The House bill cuts $483 million in programs designed to allow the elderly and disabled to access home-based Medicaid services helping them to avoid more expensive and institutional setting.
    
2. The House cuts another $300 million by asking the federal government to grant Minnesota a waiver to make significant changes to the state’s Medical Assistance (MA) program, allowing for greater flexibility to in how Minnesota uses the funds.
    

3. The House bill would also cut managed care rates by $293 million or 10% and assumes the reduction would be achieved through cuts targeted to high cost providers.
    

4. Another $216 million in savings is achieved by cutting fee-for-service reimbursements to high-cost providers.
    

Some of the other provisions in the House bill include:

• Eliminating eligibility for 7,200 MinnesotaCare for adults without children over 200 percent of poverty ($21,780 for an individual).

• Converting the MinnesotaCare program for enrollees over 133 percent of poverty ($14,300 for an individual) to a defined contribution plan, where individuals would be given a set amount to purchase health insurance in the private market. 

• Reducing Medical Education and Research (MERC) funding and changing criteria for fund distribution.

• Prohibiting DHS and MDH from spending any new federal grant money, or renewed grants, without approval from 3 of the 4 HHS chairs and ranking minority members

The Senate bill primarily relies on direct cuts but also makes sweeping changes to public programs.  It cuts $1.6 billion out of the general fund and $263 million out of the Health Care Access Fund.  Some of the highlights include:

• Providing recipients in the Medical Assistance (MA) and MinnesotaCare with household income above 75 percent of poverty ($8,200 for an individual) with subsidies to purchase coverage in the private market.  This would require a federal waiver.

• Repealing the early federal MA expansion for adults without children earning below 75 percent of poverty that was authorized by the Governor in January, resulting in the loss of federal funds.  It then revives a limited state-funded General Assistance Medical Care program using the hospital-based Coordinated Care Delivery System.

• Eliminating coverage for chiropractic, podiatry, specialized therapies, eyeglasses and prosthetics for adults.

• Eliminating MA for legal, non-citizens.

• Eliminating funding for a number of loan forgiveness funds for physicians.

• Eliminating funding for MERC.

• Cutting managed care payments by 10 percent, delaying hospital rebasing, and cutting payments to nursing homes, the disabled, mental health and CD programs.

• Transferring $157 million from the Health Care Access Fund (HCAF) to help balance the state’s general fund deficit.

• Prohibiting state funds from being used to plan for or implement the federal Affordable Care Act until it has been affirmed by the Supreme Court.

• Banning human cloning, which may impact the ability to do stem cell research.

• Prohibiting the state from using state funds or accepting federal funds for family planning.

• Changing the state’s Newborn Screening Program from an ‘opt-out’ to an ‘opt-in’ program, ends the storage of samples, and deletes the state’s registry of samples.

• Eliminating CALS funding

Both the Senate and House HHS budgets have passed their respective HHS committees.  The Senate bill has passed out of both the full Finance Committee and Senate floor, while the House bill awaits action by the Ways and Means Committee before consideration by the House.  Given the enormous differences between the two proposals, the bill will be referred to a conference committee will reconcile the differences.  A veto by Governor Dayton is likely.

Governor Announces Competitive Bidding for Public Health Programs
Governor Mark Dayton signed an Executive Order on March 23 making sweeping changes in the way Minnesota handles our public health care programs by introducing more competition and transparency aimed at saving the state money in the fastest-growing part of its budget.  Dayton's plan would require health plans to compete to receive a contract to become the payer for the state's subsidized health care based on cost and outcomes, rather than negotiating prices based on history.  The Executive Order also calls for a new public accounting of how the state's managed health care dollars are spent on public programs, including a website to display the programs' contracts and performance.   Click here to read the Governor’s press release and Executive Order. 

Chiropractors Seek Expanded Scope
In a reprise of legislation introduced during the 2010 legislative session, a bill has been introduced that would seek to expand the definition and scope of chiropractic services.

The bills, HF 1334 and SF 1056 are being authored by Rep. Tara Mack (R – Apple Valley) and Sen. Sean Nienow (R – Cambridge).  The proponents of the legislation state that they are simply “updating” the Chiropractic Practice Act to more readily reflect current practices.  The text of the bill, however, potentially suggests a problematic expansion.

Adding a new definition to current law, the bill broadly defines “chiropractic” as the “the health care discipline that emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery.”  The bill would also authorize licensed chiropractors to use “all types of diagnostic imaging that may be necessary,” a proposed statutory change that is far more expansive than current law.  In addition, the bill would allow chiropractors the authority to use the term “chiropractic physician.”  The bill’s expansive language creates many questions around the statutory limits on the scope of practice of chiropractors, and may well authorize them to offer mental health and nutrition counseling.

A growing coalition has come together to challenge the proposal, physicians, physical therapists, health plans, and dieticians.  Given the legislature’s current focus on the budget solution, it seems unlikely that this bill will receive a hearing in the next weeks.   That said, we’ll continue to follow this issue closely. 

Cuts to Higher Education, Anti-Cloning Provision Included in Senate
The House Higher Education bill would cut $201 million from the state’s college systems and $229 million from the University of Minnesota.  The Senate bill cuts colleges by $167 million and the University by $243 million.  Both bills include tuition caps.  The overall reduction in higher education funding is 14.1 percent to the “forecast base” for the next biennium.  According to the University, the general fund appropriations in both bills will be less than then amount the U received in 1998.  A sample letter to legislators opposing the cuts to the University and MERC is posted on the MAFP website.

Both bills include funding for the University/Mayo Clinic Genomics Partnership, however, at differing level.  The House provides full funding of $8 million per year and the Senate $6.98 million per year. 

The issue of human cloning also found its way into the Senate higher education bill.  It prohibits the use of state funds or federal funds received by the state to either support human cloning or pay for any expenses incidental to human cloning.  The definition of "cloning" prohibits the generation of any genetically identical copy of an organism at any stage of development.  This would, in effect, ban the process of stem cell research using any public funds.  The University of Minnesota’s Academic Health Center, the Mayo Clinic, and LifeScience Alley actively opposed this provision.  LifeScience Alley distributed a letter noting that the legislation would have a “chilling effect on legitimate medical research that is not related to human cloning…forcing them to choose somewhere other than Minnesota (to conduct research).”  The letter also points out that their members do not perform research to conduct human cloning but do develop treatments for chronic and debilitating diseases.

- Dave Renner, MAFP Legislative Representative
(drenner@mnmed.org, 612-362-3750, 1-800-342-5662)