The 2019 state legislative sessions are in full swing, with dozens of new health care-related bills introduced every day. Bills addressing trauma funding, injury prevention, out-of-network billing, physician Maintenance of Certification (MOC), and scope of practice have begun to make their way through state capitols across the country. In response, the American College of Surgeons (ACS) State Affairs staff has sent Action Alerts to nearly 2,900 Fellows, tracked more than 1,200 bills that would affect surgical care, and participated in eight chapter lobby day events. In spite of this early progress, the sessions are far from over, which means that State Affairs staff will continue to advocate on behalf of surgeons and patients, while working to stay on top of surgery-specific legislation in all 50 states.
Bleeding control kits
The ACS has championed the Stop the Bleed® program—a nationwide campaign that empowers ordinary citizens to save lives in the event of a traumatic bleeding injury—since its inception in 2012. Similar to cardiopulmonary resuscitation training, Stop the Bleed allows citizens to act quickly in the event of a medical emergency by teaching bystanders how to most effectively control severe bleeding until first responders arrive.
Over the course of the past several years, hundreds of thousands of Americans have been trained in bleeding control techniques, and Stop the Bleed has achieved national recognition. Building on this success, many states have introduced legislation that would mandate the installation of bleeding control kits in public schools and government buildings. By training students, teachers, and public servants to stop severe bleeding and by ensuring that tourniquets, gauze, and other medical supplies are readily available, legislators aim to improve survival rates in schools and communities across the U.S.
One state taking affirmative steps to ensure the well-being of its students is Indiana. On January 3, state Rep. Randy Frye (R) introduced H.B. 1063, which requires the installation of bleeding control kits in all Indiana public schools by 2020. The bill was cosponsored by state Rep. Bradford Barret, MD, FACS (R), an active member of the ACS Indiana Chapter. Dr. Barret, working with the chapter and other stakeholders, succeeded in getting H.B. 1063 introduced and unanimously passed in the House 99–0 and in the Senate 48–0. Much of the bill’s success was attributable to the fact that private stakeholders have provided most of the funding for the kits. And, because Indiana taxpayers will bear no direct cost, H.B. 1063 has engendered broad bipartisan support.
At least six other states have introduced bills mandating the installation of bleeding control kits in schools or other public places—California, Massachusetts, Missouri, New York, Tennessee, and Texas—while the Louisiana Chapter is working to identify a sponsor for a bill when the legislature convened in April. Tennessee Chapter President George Maish, MD, FACS, and Cathy Wilson, RN, MSN, ACNP-BC, Vanderbilt University Medical Center, Nashville, testified at hearings of the House K–12 Subcommittee and Senate Education Committee on March 6 in support of H.B. 215 and S.B. 259 to require the installation of bleeding control kits in schools and Stop the Bleed training for school personnel. An amended version of S.B. 259, which makes the purchase of bleeding control kits optional but training mandatory, passed out of committee and at press time was awaiting further action in the Senate. The House Education Committee agreed to incorporate the amendment to S.B. 259 into the language of H.B. 215. That bill was heard in the House Education Committee on March 20, with testimony from Timothy Nunez, MD, FACS, and Christopher Brown, CCP, representing the Tennessee Chapter. Both bills continue to move through the legislative process with session adjournment scheduled for May 8.
Although members on both sides of the aisle tend to support these bills, several state legislatures have failed to enact similar legislation requiring bleeding control kits in schools or public places. Passage of similar bills in 2018 was unsuccessful. Georgia and North Carolina secured funding to purchase kits for schools through the budget process, but other state legislatures have failed to enact legislation largely because of the financial commitment necessary to purchase kits.
Arkansas has taken a novel approach to the challenge of securing funding for kits with the introduction of H.B. 1014. Instead of requiring that kits be installed in public schools, H.B. 1014 requires that every student complete a bleeding control course to graduate from high school. So far, the legislation has been well received and if passed could set the stage for a follow-up bill next year, which would appropriate money for bleeding control kits in Arkansas schools.
Three bills were introduced in 2019 in Texas with the intent to eliminate the Texas Driver Responsibility Program, which generates an estimated $71 million in funding for the state trauma system. Two of the bills, S.B. 191 and S.B. 87, would replace the lost revenue with either an increase in registration fees or a temporary increase in traffic fines. The third bill, H.B. 550, would gradually phase out the program with no identified revenue replacement. In the later part of the session, another bill, H.B. 2048, was introduced to get rid of the program and implement an alternative revenue source, and this bill seemed to have some traction.
In Connecticut, Sen. Martin Looney (D) introduced a bill that would prohibit trauma centers from charging trauma activation fees. The Connecticut Chapter of the ACS opposed the legislation and provided testimony February 11 before the Joint Committee on Public Health. In addition, the chapter sent grassroots Action Alerts asking Connecticut Fellows to contact committee members to urge their opposition to the bill. Since then, the bill has remained in the committee but is still active. The Connecticut Chapter will continue to monitor the bill and take further action as necessary.
In New Jersey, a six-bill package would establish a hospital-based violence intervention program. The legislation establishes programming for hospitals and trauma centers with sections that address funding, counseling, and Medicaid payments. The New Jersey Chapter is working with the sponsor to build support for the bill. Another hospital-based violence intervention program bill, A.B. 166, was introduced in California and would extend Medi-Cal benefits to beneficiaries who participate in hospital-based violence prevention programs.
In Connecticut and Nebraska, legislation has been introduced on the use of helmets while driving or riding on a motorcycle. The Connecticut Chapter presented testimony February 25 to the Joint Transportation Committee in support of H.B. 7140, which would require a person to wear a helmet while on a motorcycle. Meanwhile, the Nebraska Chapter opposes L.B. 378—legislation that would eliminate the requirement to wear a helmet while on a motorcycle. Proposed legislation in Massachusetts, Virginia, Washington, and West Virginia would weaken existing state law by exempting adults 21 years or older from the requirement to wear a helmet, whereas a bill in Iowa would create a universal helmet law for all motorcycle riders and passengers. Legislation in New York, A. 214 and S. 320, calls for the state Department of Transportation to study the efficacy of motorcycle helmets in preventing injury.
The ACS Commission on Cancer (CoC) and other stakeholder organizations continue to monitor and engage on cancer-related state legislation, such as expanding health insurance coverage for breast, cervical, colorectal, and prostate cancer; raising the age for tobacco purchase to 21 years old; and protecting minors from the harmful effects of tanning beds, as well as permitting student use of sunscreen products at school and school events.
Legislation to expand coverage for three-dimensional (3-D) breast tomosynthesis mammography has been introduced in Hawaii, Iowa, Massachusetts, Minnesota, and Oklahoma, and a bill introduced in New Hampshire would clarify the reimbursement rate for the screening. New Hampshire expanded coverage for 3-D mammography in 2018. The ACS sent letters of support for the bill in Hawaii, H.B. 481, and New Hampshire, S.B. 58. The Hawaii House Committee on Finance passed H.B. 481, and the New Hampshire State Senate passed S.B. 58.
In addition to 3-D mammography, other legislation has been introduced to improve access to cancer screenings, including breast cancer screening coverage and access legislation in Connecticut, Illinois, New York, Pennsylvania, Texas, and West Virginia. Legislation that New Mexico Gov. Lujan Grisham (D) signed into law February 4, H.B. 66, requires patients receiving a mammogram to be given written notification that dense breast tissue was detected during the screening. Similar bills are pending in Georgia, Illinois, and Oklahoma.
Screening bills for colorectal cancer have been introduced in Maine, Massachusetts, Mississippi, New York, and Rhode Island. In addition, a bill to provide lung cancer counseling and screening for MaineCare recipients was introduced in Maine, and a bill in Missouri would establish two pilot programs to provide screening and treatment services—one in St. Louis and one in Pemiscot, New Madrid, or Dunklin county.
Tobacco 21, the advocacy campaign to increase the minimum age to purchase tobacco products from 18 years old to age 21, continues to gain in popularity, with 17 states introducing legislation in 2019: Connecticut, Illinois, Indiana, Iowa, Maryland, Minnesota, Mississippi, New Hampshire, New Mexico, New York, Oklahoma, Tennessee, Texas, Vermont, Virginia, Washington, and West Virginia. Virginia Gov. Ralph Northam (D) signed H.B. 2748 into law February 21. Seven states, including California, Hawaii, Maine, Massachusetts, New Jersey, Oregon, and Virginia, restrict tobacco sales to 21-year-olds. The Washington State House of Representatives passed H.B. 1074 February 20, sending the bill to the Senate for consideration, while House committees in Illinois and Minnesota and a Senate committee in New Hampshire advanced similar bills. A bill in Mississippi is the only one to fail as of press time.
Efforts to establish prohibitions on access to tanning beds for individuals younger than 18 years old are ongoing. Arizona, Indiana, Iowa, Maryland, Michigan, Missouri, Nebraska, and Montana introduced legislation on tanning bed restrictions. The bill in Arizona, S.B. 1119, failed to pass in the Senate Commerce Committee, and the Montana bill, S.B. 21, initially tabled in committee, was pulled directly onto the Senate floor and scheduled for a third reading and vote. The legislation in Nebraska, L.B. 140, was discussed at a committee hearing, but no action was taken. Two bills in Maryland were scheduled for committee hearings February 27−28.
The College and the CoC continue to participate in a coalition of health care organizations that support the enactment of laws that would allow students to possess and use sunscreen products on school grounds and at school-affiliated events. Legislation on this issue is pending in Arkansas, Maine, Massachusetts, Missouri, Rhode Island, New Jersey, and the District of Columbia.
Physician MOC refers to the process that surgical and medical specialty boards use to verify that the physicians whom they have certified continued lifelong learning, self-assessment, quality improvement, and adherence to professional standards of practice. The ACS maintains that board certification and continuous certification are necessary to affirm that surgeons have the educational background and competencies needed to provide quality care. This verification process is integral to ensuring that health care professionals have the rare privilege of self-regulation. At this time, legislation restricting the use of MOC has been introduced in Arkansas, Connecticut, Indiana, Massachusetts, New Jersey, North Dakota, Utah, and Virginia.
The Virginia Chapter of the ACS successfully opposed H.B. 1967, which died in committee January 29. Bills in Arkansas, Massachusetts, and Rhode Island remain active but have not yet been scheduled for hearings or votes in committee. Bills in Indiana and North Dakota, on the other hand, have passed through the committee process and have been voted out of the first chamber.
In Indiana, the state chapter worked to oppose S.B. 203—legislation that would restrict the use of MOC for licensure, reimbursement, and hospital privileging. Don Selzer, MD, FACS—one of the Chapter’s two Ellenberger Award recipients for outstanding work in advocacy—testified on S.B. 203 January 24 before the Senate. In addition, the chapter sent Action Alerts to surgeons in the state, asking that they contact their elected officials to oppose the bill. Despite these efforts, the bill’s sponsor, Sen. Liz Brown (R), succeeded in moving the bill through the Senate and into the House. The Indiana Chapter will continue to communicate with elected officials in the House to educate them on MOC and urge them to oppose S.B. 203. Furthermore, ACS State Affairs staff will continue to monitor all active MOC bills and work with chapters as needed to oppose legislation that would weaken MOC.
State Chapter Lobby Days
The Chapter Lobby Day Grant Program began in 2010 as a way to encourage state chapters to get more involved in advocacy by providing surgeon advocates with the opportunity to engage with their elected officials face-to-face. Each year, participating chapters may apply for a grant of up to $5,000 or an enhanced grant of $15,000. Chapters are awarded only one grant per year and must match at least half of the funds provided by the College; for example, a $5,000 grant recipient would be required to match $2,500 of its own funds.
This year, a record 27 states are participating in the Chapter Lobby Day Grant Program. Michigan received the College’s enhanced grant of $15,000 to help the chapter pursue comprehensive trauma funding legislation in the state. Michigan remains one of the few states in the U.S. without a comprehensive statewide trauma system.
To date, lobby days have occurred in Arizona, California, Connecticut, Florida, Georgia, Indiana, Kansas, Maine, Maryland, Nebraska, New York, Oregon, Tennessee, Texas, and Virginia. Chapters hosting lobby days later this year include Alabama, Arkansas, Illinois, Massachusetts, Michigan, Minnesota, Nevada, North Carolina, Ohio, Pennsylvania, Washington, and Wisconsin. Learn more about the ACS Chapter Lobby Day Grant Program at facs.org/advocacy/state/chapter-grant.
While the debate on Medicare for All is occurring at the federal level, states are moving forward with their own plans for expanding health insurance coverage for their residents, including proposals to create state-run health systems in Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, and Rhode Island. Other proposals seek to expand state Medicaid coverage to a larger pool of residents with higher incomes or with disabilities who traditionally would be ineligible. States where related bills are under consideration include Hawaii, Missouri, Montana, New Mexico, Tennessee, and Texas. Washington has a bill to create a workgroup to study the possibility of a publicly funded universal health care system.
New York’s proposal, A. 5248/S. 3577, would provide health care coverage for all New York residents, including all benefits covered by Medicaid, Medicare, Child Health Plus, and Affordable Care Act (ACA) mandates. Private health insurers would no longer provide coverage in the state. The plan would be paid for through increases in payroll and nonpayroll taxes, such as levies on investments. On February 28 the New York Chapter submitted a memorandum of opposition to A. 5248 to the Assembly Health Committee.
The bills are similar to the versions that the New York Assembly approved in 2018. The ACS New York and Brooklyn-Long Island Chapters and Manhattan Council advocated in 2018 that legislators oppose the previous version of the single-payor proposal, raising concerns about potential negative effects on patient care in New York. The New York Senate did not vote on the legislation in 2018, but the chamber was controlled by Republicans at that time. Republicans lost their majority in the November 2018 election, and in 2019, Democrats control the New York Assembly, Senate, and Governor’s office.
Optometrists again are pushing state legislation to expand their scope of practice to include surgical procedures, such as injections and laser surgery. Legislation has been introduced in Arkansas, Illinois, Iowa, Maryland, Minnesota, Nebraska, Texas, Vermont, and Wyoming. The College, in collaboration with other physician groups, sent a letter of opposition and initiated an Action Alert to members asking them to contact the Maryland Senate Energy, Health and Environmental Affairs Committee in an effort to defeat optometrist scope expansion S.B. 447. The ACS also intervened on other scope-of-practice issues, including submitting letters in opposition to a bill in Arkansas, S.B. 184, which would authorize the independent practice of certified registered nurse anesthetists, and offering support to the Indiana Chapter’s efforts to testify in opposition to H.B. 1097 on independent practice of advanced practice nurse practitioners.
For the last several years, public attention has turned to concerns about the practice of balance billing, where a patient receives an unanticipated medical bill following an insurer’s refusal to pay all or a portion of claim submitted by an out-of-network physician. This practice often occurs in the provision of emergency care, but more recent examples in the media have highlighted similar situations in the provision of nonemergency care, not only raising awareness in the state legislatures but also in Congress. To date, at least 23 states have considered legislation addressing unanticipated billing and network adequacy in some way, including Colorado, Connecticut, Georgia, Hawaii, Kentucky, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, Washington, and West Virginia.
The problem of unanticipated out-of-network bills is complex and requires a balanced approach to resolve. Chapters and Fellows should collaborate with their colleagues in their states, including state medical societies and state specialty societies, to develop solutions that will work best for their state.
Bariatric surgery coverage
The Kansas and Connecticut Chapters are leading efforts to enact legislation to expand essential health care insurance benefits to include coverage for bariatric surgery. The Connecticut Chapter testified February 14 before the Joint Committee on Insurance and Real Estate in support of S.B. 317. The Kansas Chapter has held preliminary meetings with House Majority Leader Dan Hawkins (R) and Kansas Insurance Commissioner Vicki Schmidt to discuss the possibility of introducing a bill in the legislature or pursuing an alternative regulatory approach to expanding coverage.
Engagement of ACS Fellows is critical in ensuring that surgeons continue to be leaders in patient safety and health care quality. Fellows are encouraged to support ACS advocacy efforts by participating in state chapter meetings and lobby days, building relationships with elected officials (critical to effective grassroots advocacy), speaking about public policy issues with colleagues, responding to grassroots Action Alerts from the College, and attending the annual ACS Leadership & Advocacy Summit.
The ACS State Affairs team is always available to answer questions and provide background information regarding state issues and policy programs. Numerous state advocacy resources are available on the College’s website, and Fellows may contact us any time at firstname.lastname@example.org or at 202-337-2701.