By Andy Marso
June 17, 2015
When the 2015 legislative session started in January, public health advocates had reason to be optimistic they could reach some of their most ambitious goals.
The Kansas Hospital Association was ramping up efforts to expand Medicaid coverage to about 100,000 uninsured Kansans with the political implications of the 2014 election over.
Newly re-elected Gov. Sam Brownback had proposed to almost triple the state cigarette tax — a prospect that won quick support from groups that fight cancer and heart disease.
Groups that had pushed for years for a mid-level dental provider license to allow Kansans better access to oral care had a new and powerful ally in Americans for Prosperity.
But by the time the dust settled on Friday — Day 113 of the traditionally 90-day session — those health policy goals and others had fallen by the wayside. By then the state’s cash-strapped budget also had opened a series of new battles for hospitals and other health care providers.
“I guess it’s time to lick our wounds and move on,” Rick Cagan, executive director of the National Alliance on Mental Illness in Kansas, said of his organization, which saw its grant funding reduced.
Cagan said this session included a couple notable successes, including a bill to allow tax-exempt savings accounts for young Kansans with disabilities. He said another bill that strengthens prohibitions on seclusion and restraint in schools was “a shining success” that will help students in “the whole range of disability groups.”
“That probably would be categorized as historic,” Cagan said. “It’s been a campaign by disability advocates for years.”
But for the most part, the 2015 session saw incremental progress or none at all on the issues public health advocates hold most dear.
After three years, proponents of Medicaid expansion finally got a public hearing on the issue — and they were prepared.
In more than 150 pieces of testimony, health care, business and religious leaders made the case for expansion as both the fiscally sound and humanely compassionate thing to do. The group was headlined by Robert Moser, a doctor who until a few months earlier had been Brownback’s secretary of health and environment.
It was an extraordinary hearing, but in the end it was just a hearing. There was no vote, no legislative follow-up, no further discussion beyond the back rooms of the Statehouse.
“We believe that this legislative session provided us an opportunity to talk more about KanCare expansion,” said Chad Austin, the Kansas Hospital Association’s senior vice president for government affairs. “We are disappointed the Legislature did not move forward to adopt expansion, but we are looking forward to speaking with legislators and others about a Kansas solution that hopefully will meet the Legislature’s approval next year.”
KanCare has been the name of the Kansas Medicaid program since 2013, when the state placed services under the administration of three managed care organizations.
Cagan said his group also remains committed to continuing the Medicaid expansion fight. He said Kansans with mental illness often are uninsured and need treatment for other chronic conditions as well as their mental health.
“I look forward to talking with some of my colleagues about how to reposition Medicaid expansion in 2016,” Cagan said. “I think we have to do it.”
Expansion could be an even heavier lift next year.
It will be an election year for all legislators, including a number of Republican senators who ousted more moderate predecessors in part on a promise to shield Kansans from President Barack Obama’s health care reforms.
Next year the Legislature would be considering Medicaid expansion for 2017, which is the first year the program would require some state money. Until then it is fully federally funded, but in 2017 the states will be required to pick up 5 percent of the cost of expanded coverage.
That amounts to about $40 million in Kansas. Austin said that would be offset because more people enrolled in KanCare would mean the state would get more money from an HMO privilege fee and Medicaid’s prescription drug rebate program.
Even so, it will be a challenge convincing legislators to approve $40 million up front after the tax-and-budget crisis that led to this session’s historic length.
Health-related budget issues
As the Legislature dragged through nearly a month of overtime, Austin and the hospitals suddenly found themselves battling a couple of unexpected budget-balancing proposals.
Some legislators looking at ways to close a $400 million gap suggested ending sales tax exemptions for nonprofits, which would have cost 115 Kansas hospitals approximately $70 million.
Meanwhile, Brownback’s office warned that without tax increases, he might be forced to balance the budget with across-the-board cuts. Included in those threatened cuts was a reduction in Medicaid provider reimbursements, something the governor repeatedly said would not happen when the state switched to managed care.
In the end, legislators raised taxes and left the sales tax exemptions untouched, but only after legislative leaders promised the tax committees would have hearings on them next year.
“We were disappointed such a major policy decision would be thrown into the discussion without any legislative debate at the conclusion of the session,” Austin said. “Toward that end, we look forward to the opportunity to demonstrate how the not-for-profit sales tax exemption benefits communities through the services we provide that may not otherwise be available.”
The session also started with legislators, including the House majority leader, expressing a desire to funnel more funds to beleaguered Osawatomie State Hospital, one of the state’s two hospitals for Kansans with severe mental illness.
The hospital did get an increase of $500,000 on its $29 million budget, but that was in question until lawmakers passed the last-minute tax increase.
Osawatomie and the state’s other three hospitals — including two for Kansans with developmental disabilities — were in line for budget cuts if legislators hadn’t pushed the tax package through.
Concerns remain about funding and staffing levels at the hospitals.
Cagan said his group does not want to go back to the days when people with mental illnesses were routinely warehoused in institutions, but “sometimes people need a hospital bed and we can’t provide one.”
He’s encouraged by the Brownback administration’s appointment of a committee to reform the state’s mental health system and try to minimize the need for crisis beds.
But the tight state budget limits what can be done. Cagan’s group had to reapply for grant funding it formerly could count on and ended up getting less than in past years.
“It was a very challenging thing this year to insert any language with dollar signs on it,” Cagan said.
Brownback’s proposal to increase the state’s cigarette tax from 79 cents per pack to $2.29 per pack was one of his early answers to the budget crisis.
But that was a non-starter for many legislators and Brownback never pushed it aggressively. That left the lobbying work to a broad coalition of public health advocates, who said the tax would cause about 25,000 smokers to quit and another 25,000 kids to never take up the destructive habit.
They say the approved cigarette tax hike of 50 cents per pack will have far less effect on smoking rates.
“The tobacco tax is a gain but a modest one,” said Shannon Cotsoradis, president and CEO of Kansas Action for Children. “I think we all hoped for more.”
Advocates from the American Cancer Society’s Cancer Action Network, the American Heart Association and Kansans for a Healthy Future all characterized the final cigarette tax increase as “a missed opportunity.”
“Significant increases in the price of cigarettes have big health impacts,” Kevin Walker, regional vice president of advocacy for the American Heart Association, said after Brownback signed the tax bill. “But small increases, like the 50-cent tax passed today, do not.”
Some are concerned that the cigarette tax increase actually could have a detrimental effect on public health if it causes smokers to switch to cheaper products like smokeless tobacco to satisfy their nicotine cravings.
“It’s devastating,” Tanya Dorf Brunner, executive director of Oral Health Kansas, said of the health effect of products like snuff and chew.
Brownback’s original proposal coupled the cigarette tax hike with a substantial increase in the tax on smokeless tobacco products.
Dorf Brunner said that would have been a better policy, but lawmakers left the tax on smokeless tobacco where it’s been for about the last 40 years.
“Just tax parity is what we’ve been after for years,” she said.
Other budget-balancing provisions also could affect Kansans’ health or health care.
The increase in the privilege fee on health maintenance organizations could increase premiums for customers with those plans, and the sales tax hike used to balance the budget means Kansans will pay the second-highest state sales tax on food in the country.
“We have to be concerned about the impact that will have for access to nutritious food for low-income and moderate-income families,” Cotsoradis said.
Mid-level dental and nurse practitioners
Some progress was made this session on scope-of-practice initiatives intended to provide underserved communities greater access to health care. But the laws did not change.
For several years Cotsoradis’ group has led a coalition pushing for licensing of mid-level dental providers.
The bill didn’t pass this year. But it did get hearings in the House and Senate, which Cotsoradis characterized as a step forward.
“It was the best dialogue we’ve had to date over the issue,” she said.
Cotsoradis pointed to testimony from a diverse range of supporters, including Wichita State University President John Bardo and leaders of Americans for Prosperity.
“We’ll be back next year, there’s no doubt,” Cotsoradis said.
The Kansas Dental Association still opposes the bill, she said, but the next step is to visit with individual dentists and try to earn their support by explaining how licensing mid-level providers could help them expand their practices.
The bill would expand what services mid-level practitioners could perform, but it would require them to work under the general supervision of a licensed dentist.
That’s a major difference from advanced practice nurses, who are seeking the authority to practice independently.
Their bill also quickly stalled, amid opposition from a lobbying group that represents Kansas doctors.