Call to Order and Roll Call
The first meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, June 16, 2010, at 1:00 p.m., in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:10 p.m., and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Tom Buford, Julian M. Carroll, Perry B. Clark, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Katie Kratz Stine, and Jack Westwood; Representatives Bob M. DeWeese, Jim Glenn, Brent Housman, Tim Moore, Ruth Ann Palumbo, Susan Westrom, and Addia Wuchner.
Guests: Robin Karr; Joy Johnson Wilson, Health Policy Director, Federal Affairs Counsel, National Conference of State Legislatures, Washington, D.C.; Janie Miller, Secretary, Cabinet for Health and Family Services; Nathan Goldman, Kentucky Board of Nursing; Eric T. Clark, Kentucky Association of Health Care Facilities; Bill Doll and Marty White, Kentucky Medical Association; Sheila Schuster, Kentucky Mental Health Coalition; and Ellen Kershaw.
LRC Staff: DeeAnn Mansfield, CSA, Miriam Fordham, Ben Payne, Jonathan Smith, Gina Rigsby, and Cindy Smith.
Consideration of Referred Administrative Regulations
A motion to approve the referred administrative regulations, 201 KAR 20:240 – establishes fees for licensure, registration, examination, renewal, reinstatement, and continuing education required by the Board of Nursing, and 201 KAR 20:490 – establishes the scope of practice for administering medicine or treatment by a licensed practical nurse as it relates to intravenous therapy was made by Senator Pendleton, seconded by Senator Clark, and adopted by voice vote.
Hysterectomy Alternatives and After Effects
Robin Karr stated that changes need to be made to the informed consent laws pertaining to hysterectomy that will truly inform and educate women in regard to the functions of the female sex organs throughout their lives and the consequences of them being removed. By the age of 60, approximately one-third of all American women have had a hysterectomy. In the South, women are 50 percent more likely to have a hysterectomy than in any other part of the country. Hysterectomy is the number one unnecessary surgery being performed in America today. According to Ms. Karr, the surgery generates billions of dollars for gynecologists and drug companies, but the devastation to women, society, and the health care system is beyond measure. Today, it is estimated that less than one percent of hysterectomies are performed for gynecological cancers. Several published articles state that a hysterectomy, especially ovary removal, can cause heart disease, bone loss, dementia, Parkinson’s disease, and memory loss. She suggested that a video be presented to every woman who has been told she needs a hysterectomy that would contain the information needed to make an informed decision about hysterectomy and its consequences and the available alternatives. Information provided by Ms. Karr is included in the meeting folder in the LRC Library.
Senator Carroll made a motion, seconded by Representative Glenn, and approved by voice vote that the information provided by Ms. Karr be forwarded to the Department for Public Health, Cabinet for Health and Family Services, for its response and requested information be sent to the committee about Kentucky’s informed consent laws as they relate to hysterectomy procedures.
Health Care Reform
Joy Johnson Wilson, Health Policy Director, Federal Affairs Counsel, National Conference of State Legislatures, Washington, D.C., reported that the Patient Protection and Affordable Care Act, P.L. 111-148, was signed into law on March 23, 2010. The Health Care and Education Reconciliation Act of 2010, P.L. 111-152, was signed into law on March 31, 2010 and amended some of the provisions of P.L. 111-148. The bills are now referred to as The Affordable Care Act. Because the reconciliation process was used, many technical and perfecting amendments were not in order. The legislation maintains an employer-based health care system; expands and modifies Medicaid to become the foundation for the reformed health care system; requires individuals to obtain qualified coverage; establishes subsidies for premiums and cost-sharing for individuals with incomes between 133 percent and 400 percent of the federal poverty level (FPL); and initially establishes health care exchanges to help individuals and small businesses to purchase qualified coverage.
The law fundamentally changes the state’s role in Medicaid by changing the status of Medicaid in relation to the rest of the health care system in the United States. Ongoing state budget issues as related to Medicaid include underfunding of the underlying program; failure to address coverage for undocumented immigrants; failure to include a statutory countercyclical trigger; implications of a reduction in federal assistance in the future; and no serious effort to address long-term care. The law also gives states more flexibility and the transformation of the Medicaid program is left largely to state governments. The challenges will be new eligibles versus others; systems upgrades; staffing; workforce and infrastructure; infrastructure improvements; marketing of the new Medicaid; maintaining public support; and improving quality. The Medicaid expansion establishes a national minimum eligibility level at 133 percent of the FPL with eligibility to be based on income and adds new mandatory categories of Medicaid-eligibles such as single, childless adults who are not disabled, parents, and former foster care children who have aged out of the system. One option for states is to begin expansion for certain non-elderly individuals with incomes up to 133 percent of the FPL effective April 1, 2010. Coverage would be reimbursed at the state’s regular Medicaid Federal Medical Assistance Program (FMAP) rate. An enhanced FMAP for new eligibles will be implemented between 2014 and 2020. Medicaid expansion features include temporary maintenance of effort and eligibility, the option of state financial hardship exemption from maintenance of effort, and Medicare rates for Medicaid primary care physicians for 2013 and 2014.
New Medicaid mandates are to phase in Medicaid rates for primary care providers for 2013 and 2014 only, coverage of preventive services with no cost-sharing, reimbursement of Medicaid services provided by school-based health clinics, quality measures for adult beneficiaries, non-payment for certain health care acquired conditions that mirrors the Medicare provision, state use of National Correct Coding Initiative, coverage of comprehensive tobacco cessation services for pregnant women, and background checks for direct patient access employees of long-term care facilities and providers. The Centers for Medicare and Medicaid Services (CMS) announced the availability of $160 million in Affordable Care Act grants to support all states and the U.S. territories for a multi-year Nationwide Program for National and State Background checks on direct patient access employees of long-term care facilities and providers. Demonstration projects available include evaluation of integrated care around a hospitalization, Medicaid global payments, Pediatric Accountable Care Organization (ACD), and Medicaid emergency psychiatric care.
Additional provisions under the Affordable Care Act include new prevention and wellness programs; prescription drug rebates; long-term care programs; establishment of a federal Coordinated Health Care Office with the CMS for dual eligibles; and a reduction in Disproportionate Share Hospital (DSH) payments. Employer responsibilities include penalties for failure to provide coverage and large employers with waiting periods. Beginning in 2014, individuals are required to maintain minimum essential coverage. Exceptions to the individual responsibility requirement to maintain minimum essential coverage are made for religious objections, illegal immigrants, and incarcerated individuals. Health insurance reforms that will be implemented now are temporary high-risk pools and new rules on minimum medical loss ratios. Effective for plan years beginning on or after September 23, 2010, there will be a prohibition on rescissions except for fraud; extension of dependent coverage for young adults until their twenty-sixth birthday; limits on pre-existing condition exclusions for children; limits on lifetime and or annual caps; and reinsurance for early retirees that apply to state and local government plans. Health insurance reforms that will be implemented later are a prohibition on pre-existing condition exclusions; guaranteed issue and guaranteed renewal; premium rating rules; non-discrimination in benefits; mental health and substance abuse services parity; prohibition on discrimination based on health status; and a prohibition on annual and lifetime caps.
States have a number of grant opportunities under the health care reform law including grants to create and strengthen insurance rate review processes. Funding is provided to states, tribes, and territories to develop and implement one or more evidence-based maternal, infant, and early childhood visitation models. The law also creates a new national long-term care insurance program called Community Living Assistance Supports and Services (CLASS). Copies of the presentation and handouts are included in the meeting folder in the LRC Library.
In response to a question from Senator Denton, Ms. Wilson stated that states still have flexibility except for the new mandates.
In response to a question from Representative Burch, Ms. Wilson said that parity is still a requirement for mental health and substance abuse services. At some point, coverage cannot be denied for any pre-existing condition.
In response to questions from Senator Stine, Ms. Wilson stated that a medical home is a state option, and one of the new mandates is the reimbursement of Medicaid services provided by school-based health clinics. Illegal aliens will be exempt from the health insurance coverage mandate. Child support would not be figured into an individual’s income but will be determined by the modified adjusted gross income as defined by the Internal Revenue Service (IRS).
In response to questions by Senator Denton, Ms. Wilson stated that the coverage of comprehensive tobacco cessation services for pregnant women is a new, unfunded mandate. Federal law requires that anyone who needs treatment in the emergency room will be stabilized even if are unable to pay for services.
In response to questions from Senators Denton and Carroll, Ms. Wilson stated that the DSH payments to states will be reduced using the DSH Health Reform Methodology, but one percentage point would be added to the regular FMAP for coverage of preventive services. An incentive grant is available that would give a state the flexibility to choose and fund the prevention of chronic diseases and promote healthy lifestyles.
In response to questions from Senator Westwood, Ms. Wilson stated that financial penalties by the IRS will be imposed on individuals who do not get coverage. No federal dollars can be used for abortions, but an individual can purchase a separate rider to cover the procedure.
Janie Miller, Secretary, Cabinet for Health and Family Services, stated the cabinet is collaborating with interested parties to develop a strategic plan to implement the federal mandates. There needs to be a coordinated strategic approach that would streamline opportunities and cost efficiencies to make sure that the best evidence-based choices are made for Kentucky. The challenges include a shortage of primary care providers to meet the demand; how to structure payment for services; limited federal funding; and the impact on the current budget. States need more details from the federal government concerning eligibility and regulation of rates. The cabinet will look at all available options and decide which would be beneficial and cost effective to implement. The legislation has more unfunded mandates. Basic information will be provided on the cabinet’s web site concerning the timelines and submission of the letters of intent to the federal government.
In response to questions from Representative Westrom, Secretary Miller stated the cabinet will work with the General Assembly concerning physician extenders providing care in order to reduce expenditures and costs.
In response to comments made by Senator Clark, Secretary Miller stated the cabinet would need to have funds available to match the federal government allocation.
Written information about the Patient Protection and Affordable Care Act provisions was provided to the committee from Sharon Clark, Commissioner of the Kentucky Department of Insurance. A copy of the information is included in the meeting folder in the LRC Library.
There being no further business, the meeting was adjourned at 4:01 p.m.