Colorado legislators share what to expect in 2015
by Susan Koontz, JD, CMS General Counsel
The first regular session of the 70th Colorado General Assembly convened Jan. 7, 2015, and with its convening comes opportunities to advance the priorities of Colorado physicians and their patients. Lawmakers on both sides of the aisle from the Joint Budget Committee and the Senate and House committees with jurisdiction over health care issues give their thoughts on the upcoming session.
The JBC has the unenviable task of balancing the state budget under the constraint of available resources, the many conflicting spending priorities and differing philosophies. “One of the big challenges we’re getting now is more federal mandates that are causing higher pressure across the whole budget,” said Sen. Kent Lambert, R-Colorado Springs, JBC chairman. The 2015 budget will be the largest in Colorado history, and health and human services spending represents the largest segment at just over $10.5 billion.
“It’s always a fight, meeting the demands of federal mandates and self-imposed mandates in the state,” said Sen. Kevin Grantham, R-Canon City, JBC member. “It’s a struggle given limited revenues and a growing population. Expanded Medicaid within the state over the last several years creates increased pressure on several other departments and we have to juggle those needs and wants across many different sectors of our society.”
As more people enroll in Medicaid, Grantham said the state has to make sure the provider rate is equitable and fair. Rep. Millie Hamner, D-Dillon, JBC vice-chair, said she is interested in pursuing targeted rate increases to encourage additional capacity and an overall increase across the board.
Rep. Dave Young, D-Greeley, is acutely aware that ensuring patients have access to specialty providers is connected to making sure those providers are adequately compensated. He previously served as vice-chair of the House Public Health and Human Services Committee. “In the big picture, we need significant Medicaid payment reform,” he said.
“All of that just adds to the pressure that is put on the JBC with all the other aspects of the budget,” Grantham said.
Additionally, the budget is challenged by a “funding knot” created by TABOR (the Taxpayer’s Bill of Rights), the Gallagher Amendment and Amendment 23. TABOR places restrictions on the amount of total general funds and cash funds that can be collected and spent by the state, and Colorado is expected to hit the TABOR limit this year, raising questions about how to handle the funds. Hamner said that while TABOR does not directly affect health care, “the end result is that fewer dollars will be available to the overall budget, making it more difficult to increase specialty rates or to fund new programs or expand existing programs.”
“At a time when we are expanding enrollments in Medicaid, when we are trying to help our schools recover from massive cuts they experienced during the Great Recession, and when we are trying to help reduce college debt load, the state will hit the TABOR limit and we’ll be faced with the constitutional requirement to provide refunds to taxpayers,” Young said. “Our budget is stretched very thin.”
Health care reform
With significant Republican victories in the November election and a few pending U.S. Supreme Court cases, it is possible that the Affordable Care Act may see challenges in Congress and in the statehouse. Lambert said there will be moves on a national level to replace or pull back on the federally mandated systems. “If that leads to some sort of impasse in Washington, D.C., especially when people are losing individual health insurance plans or group plans from their employer, the state may have to make some major changes in how we do state health care if we can’t rely on a stable federal system.”
In Colorado, “we’re in defensive mode to ensure we keep moving forward on the Affordable Care Act and that bills to try to get rid of it are not successful,” said Sen. Irene Aguilar, MD, D-Denver, former chair of the Senate Health and Human Services Committee. “I don’t see this as a real threat in the sense that the House would not let it get through, but I think there’s a chance a bill like that might make it through the Senate.”
A major part of the Colorado implementation of the Affordable Care Act is the state health insurance exchange, Connect for Health Colorado. Rep. Beth McCann, D-Denver, chairwoman of the House Health, Insurance and Environment Committee, expects to see the exchange come under additional scrutiny following an unfavorable audit, though she said there may not be any legislative changes this session.
“Despite some of the negative findings of the exchange audit, I believe the exchange has done a very good job,” she said. “They had to get set up so quickly with hiring so many people and training them on the complicated health insurance arena, policies, subsidies and all of that. There seem to be areas of improvement but overall I think they’ve done a remarkable job considering how quickly they had to put all this together.”
“I think we are going to see some ability in the future to have some more flexibility within the exchange,” said Rep. Dianne Primavera, D-Broomfield. “What we need to be working on is to make sure it runs as efficiently as possible and people get the health care that they need.”
Sen. Kevin Lundberg, R-Loveland, chairman of the Senate Health and Human Services Committee, has heard negative feedback about the exchange and the Affordable Care Act from his constituents. “Very few are satisfied with how Obamacare is working out for themselves and their families,” he said, adding that the state should allow for the development of more choices and free competition for the coverage of medical costs. “I look forward to serious discussions that will lead to putting medical decisions back into the hands of the patients and their doctor.”
Scope of practice
Aguilar said the political environment this session is more favorable for expanding the scope of practice of non-physician health care providers. She attended the Colorado Medical Society’s strategic discussion on scope of practice at the 2014 annual meeting in Vail in September. “The thing to think about is how we can safely help people with different types of education practice at the full extent of their license, and be open to that possibility of team models and apply outside-the-box thinking on how we can accomplish that goal and get good health outcomes.”
Primavera said she has heard discussions about expanding scope of practice as much as possible to increase provider supply, as well as expanding telehealth services and exploring student loan forgiveness.
Aguilar expects to see legislation related to increasing access to specialty care in Medicaid and she said she hopes to see some creative ideas come out of this session around that concept. She presented a request: “If every specialist would consider trying to see people who have Medicaid, that would help us with that need.”
Young sees great promise in the recent announcement that Colorado’s State Innovation Model (SIM) proposal was approved by the Centers for Medicare and Medicaid Services. “The integration of behavioral health with primary care is one of the top issues Northern Colorado Medical Society members identified when I met with them in late October. This integration of care is, like payment reform, one of the essential elements to ensuring improved health care for Coloradans. It’s one of my goals to support the implementation of the SIM grant in any way I can.”
McCann expects to see bills related to making marijuana edibles more easily identifiable and limiting the number of marijuana plants that individual caregivers can grow. She also expects a “death with dignity” bill to come before her committee. That bill is patterned after the Oregon bill that allows a physician to prescribe a lethal dose of medication to a patient who is in a terminal illness situation, with additional stipulations.
“We’re looking forward to the session,” McCann said. “I’m sure there will be some interesting bills. We’ll be able to get some good bills passed, and we’ll work across the aisle to try to do what’s best for Colorado.”
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