April 23, 2021: State Advocacy Update

Following strong opposition from the AMA (PDF) and the Montana Medical Association, the Montana Senate voted on April 20 to postpone indefinitely a bill that would have prohibited the provision of gender transition-related care to minor patients, effectively halting the bill. Montana HB 427 is among a raft of bills this year that would bar evidence-based care for gender diverse minors and, in some states, criminalize the practice of medicine.

The AMA opposes these legislative intrusions into clinical decision-making and has been working closely with state medical associations to vigorously oppose bills of this kind. In letters to legislators, the AMA has emphasized that it is “imperative that transgender minors be given the opportunity to explore their gender identity under the safe and supportive care of a physician.”

A bill that would help establish the nation’s first legislatively authorized overdose prevention site (OPS) pilot program is under consideration in Rhode Island. House Bill 5245 (PDF) and Senate Bill 16 (PDF) would authorize a pilot program that would be designed, monitored and evaluated to generate data to inform policymakers on the feasibility, effectiveness and legal aspects of an OPS in reducing harms and health care costs related to, among other things, injection drug use. The AMA joined the Rhode Island Medical Society in supporting the legislation.

In addition to providing the data to better inform policymakers, the bills also would “establish a multidisciplinary advisory board to provide medical, legal and lived experience will provide the state with essential information to help ensure the OPS meets the state’s goals to reduce overdose and save lives,” wrote AMA Executive Vice President and CEO James L. Madara, MD (PDF).

Dr. Madara also noted that “the implementation of one or more OPS in Rhode Island, pursuant to the structure of H.B. 5245, is particularly timely and essential due to the fact that drug overdose rates in Rhode Island—as in nearly every other state in the nation—increased in 2020.”

Dozens of states have introduced legislation over the last several months to stop insurers’ use of copay accumulator programs. Kentucky was the first state to have legislation signed into law this year, quickly followed by Oklahoma. They join states like Arizona, Illinois, West Virginia and Virginia in protecting patients from these harmful payer programs.

Copay accumulator programs, or accumulator adjustment programs, are a utilization management tool used by pharmacy benefit managers (PBM) and health insurers to restrict copay assistance from counting toward a patient’s deductible or out-of-pocket maximum. Patients are often unaware that this assistance is not counting toward their cost-sharing requirements and may, often mid-year, find they are not able to afford their medications or other health care services for them or their family when their out-of-pocket responsibilities are too high. Moreover, failure to count copay assistance toward a patient’s deductible out-of-pocket maximum means the health insurer or PBM is essentially being “overpaid.”

The new Kentucky law limits plans’ use of copayment accumulators to only those cases where there is a generic alternative available unless the brand drug was obtained through prior authorization, step therapy or insurer exceptions or appeals. The Kentucky Medical Association was a leading voice on this legislation and worked closely with a coalition of patient organizations and other stakeholders on this successful effort.

The new Oklahoma law broadly prevents insurers from discounting copay assistance from patients’ maximums out-of-pocket costs, deductibles, co-pays, coinsurance and other patient cost-sharing requirements. The Oklahoma State Medical Association played a critical role in its passage, also working closely with a local coalition of patient advocates.

The All Copays Count Coalition, a group of patient, physician and provider groups, including the AMA, is the leading voice advocating for change on this issue. The Coalition has drafted model legislation, created resources, and is supporting local coalition work to support state legislation.

For more information on the coalition’s work and available resources, please contact [email protected].

In the United States, Medicaid paid for nearly half of all births and funded over 65% of all births by Black and Indigenous mothers. These populations are disproportionately impacted by poor maternal health outcomes but are also significantly more likely to be without post-partum insurance coverage. On April 12, Illinois became the first state to extend Medicaid eligibility to new mothers for 12 months after birth. Full Medicaid benefits will be available for women with incomes up to 208% of the federal poverty level (FPL) and the state will provide continuous eligibility during the entire postpartum period. Prior to the waiver approval, eligibility was limited to 60 days postpartum.

The waiver aims to address high rates of maternal mortality, especially among women of color. Rates of maternal mortality are higher in the U.S. than any other developed country and the gap is especially great in Illinois. A report by the Illinois Department of Public Health in 2018 found that non-Hispanic Black women are six times more likely to die of a pregnancy-related condition as non-Hispanic white women.

The AMA stands in strong support of policies that will close this coverage gap such as the "Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act", introduced by Senator Dick Durbin (D-IL) and Tammy Duckworth (D-IL), which would require states to extend Medicaid and CHIP coverage to 12 months postpartum. The American Rescue Plan Act jumpstarted these efforts by establishing a temporary, optional provision to assist states in expanding these Medicaid/CHIP coverage opportunities in order to take swift movements to combat maternal mortality and severe maternal morbidity further exacerbated by the COVID-19 pandemic.

The AMA believes access to care during the postpartum period is critical to preventing pregnancy-related deaths and seeks immediate and effective action to reduce deaths linked to pregnancy and childbirth, as well as throughout the postpartum period. The AMA supports Medicaid coverage for 12 months postpartum.

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