Jan. 25, 2018: State Advocacy Update

On Jan. 12, Kentucky became the first state to receive federal approval to implement work requirements as a condition of eligibility for the Medicaid program. Beginning in July 2018, Kentucky's Medicaid expansions program, known as Kentucky HEALTH, will require non-disabled adult beneficiaries to complete 80 hours per month of community engagement activities, such as employment, education, job skills training and community service. Some populations are exempt from the new requirement: former foster care youth, pregnant women, primary caregivers of a dependent (limited to one caregiver per household), beneficiaries considered medically frail, beneficiaries diagnosed with an acute medical condition that would prevent them from complying with the requirements, and full-time students.

The approved waiver also includes provisions requiring beneficiaries to pay premiums and contribute to health care spending accounts. The accounts will be used to purchase otherwise uncovered benefits, including dental, vision, and over-the-counter medicine. Beneficiaries living at or above the federal poverty level who stop paying premiums will be disenrolled and subject to a non-eligibility period for six months. The waiver also eliminates retroactive eligibility for most populations and expands mental health and substance use disorder benefits for beneficiaries residing in an Institution for Mental Diseases.

On the same day as the approval, Governor Bevin signed an executive order directing the Health and Family Services Cabinet to terminate the Medicaid expansion program if any part of the Medicaid waiver is successfully challenged in court. Medicaid expansion in Kentucky covers over 400,000 people.

Kentucky estimates that the waiver will result in approximately 238,000 fewer Medicaid enrollees in the first year. The AMA opposes work requirements as a condition of Medicaid eligibility. For more information, contact the AMA Advocacy Resource Center.

To learn more about CMS' recent guidance issued for states seeking waivers on Medicaid work requirement, read the complete story in the national section of AMA Advocacy Update.

In response to a Montana prosecutor stating that his office will seek an order of protection restraining a pregnant female from any "non-medically prescribed use" of these substances, multiple national organizations have emphasized that treatment—not criminalization—is the optimal approach to treating patients with a substance use disorder. AMA policy has long held that treatment for a substance use disorder is a disease amenable to treatment rather than a criminal activity, and that "pregnant and breastfeeding patients with substance use disorders should be provided with physician-led, team-based care that is evidence-based and offers the ancillary and supportive services that are necessary to support rehabilitation." See examples of relevant AMA policy here and here.

In a released statement from the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Society of Addiction Medicine, March of Dimes and the National Organization on Fetal Alcohol Syndrome: "While the risks associated with drug and alcohol use during pregnancy deserve greater attention and public investment, addiction is a chronic brain disease that needs medical treatment, not criminalization based on medical misinformation and stigma. There is a strong consensus among medical and public health organizations that a punitive approach during pregnancy is ineffective and harmful to both mothers and children."

On the ground in Montana, the state medical association stressed that "we recognize that Montana communities are faced with difficult challenges, making it critical that law enforcement and medical professionals work as partners to explore options that support treatment over incarceration in recognition that drug addiction is a disease."

For more information, please contact Jean Branscum, Montana Medical Association Chief Executive Officer.

On Jan. 16, the AMA urged the Nebraska Health and Human Services Committee (PDF) to oppose Legislative Bill 687, which would enact the Advanced Practice Registered Nurse (APRN) Compact in the state. The AMA expressed that the bill would inappropriately authorize APRNs treating Nebraska patients through an APRN Compact license to practice and prescribe independently. This would undermine Nebraska law requiring Nebraska nurse anesthetists and nurse midwives to practice pursuant to a collaborative agreement with a physician, and would grant nurse anesthetists and nurse midwives prescriptive authority for the first time. The bill would also undermine Nebraska law requiring nurse practitioners to have 2,000 hours of clinical practice under physician or nurse practitioner supervision before becoming authorized to practice independently.

The AMA opposes enactment of the APRN Compact due its potential to supersede state laws that require APRNs to practice under physician supervision, collaboration, or oversight."

Contact Kristin Schleiter, senior legislative attorney, if you anticipate APRN Compact legislation in your state.

On Jan. 16, the AMA urged (PDF) the New Hampshire House Health, Human Services and Elderly Affairs Committee to oppose House Bill 1506, which would create a new licensure category of "assistant physicians" for medical school graduates who have undertaken a residency. The AMA opposes special licensure pathways for physicians who are not currently enrolled in ACGME or AOA training programs, or who have not completed at least one year of accredited graduate medical education.

If you anticipate assistant physician licensure legislation in your state, contact Kristin Schleiter, senior legislative attorney.

On Jan. 10, the AMA wrote to the Alaska Senate Labor and Commerce Committee (PDF), expressing the AMA's opposition to Alaska Senate Bill (S.B.) 120. The bill would inappropriately authorize naturopaths to prescribe medications in a manner beyond naturopaths' education and training. Because naturopathic training does not include meaningful pharmaceutical education or provide sufficient experience, the AMA believes that the bill's authorization of naturopath prescribing of prescription drugs threatens the health and safety of Alaska's patients. S.B. 120 also represents a dangerous step towards allowing naturopaths to prescribe controlled substances, authority being sought in several states across the country.

Please contact Kristin Schleiter, senior legislative attorney, for assistance in defeating naturopath licensure and prescriptive authority legislation.

• Jan. 25, 2018: Advocacy spotlight on Physicians, payers collaborate on prior-authorization relief 
• Jan. 25, 2018: National Advocacy Update