Yet Again, We Rise
CMA’s 2016 Legislative Wrap Up
By Janus L. Norman, CMA Senior Vice President of Government Relations
The delivery of health care, and its costs, continue to be at the forefront of California politics. Dramatic changes, such as the implementation of the Affordable Care Act, escalating health care premiums, consolidation of health plans, rising drug costs and the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), continue to create uncertainty in the marketplace, causing a relatively new state Legislature to question nearly every aspect of health care delivery in California. The result has been a record number of significant legislative challenges to the core policy beliefs of the California Medical Association (CMA).
“Transition” was the consistent variable in 2016. The year began with a transition of power in the Assembly as then-Speaker Toni Atkins (D - San Diego) handed over her leadership position to current Speaker Anthony Rendon (D - Lakewood). Chairs of policy committees during Speaker Atkins’s tenure worked quickly to conclude unresolved legislation from 2015, while policy chairs appointed by Speaker Rendon rushed to learn the full breadth of their policy committees’ jurisdictions. During all this time, the special legislative sessions on health care and transportation continued to convene.
Legislative transition is synonymous with opportunity — and these opportunities are both good and bad.
The continuation of the special session on health care gave CMA and the Save Lives Coalition the opportunity to beat Big Tobacco by passing the most expansive package of tobacco reform legislation in the history of the Golden State. We closed loopholes in workplace and school campus smoking laws, brought e-cigarettes under the umbrella of tobacco products, increased licensing fees, and raised the legal purchasing age to 21. But our war against tobacco is not over yet, as we take on the industry again at the ballot box in November to increase the state tax on all tobacco products in order to help fund Medi-Cal.
Our public health focus did not end with tobacco. After the tragic loss of two San Diego medical students to a drunk driver in 2015, CMA pushed for mandatory responsible beverage training for managers, servers and bartenders in establishments that serve alcohol.
We took advantage of the shift in Senate chairmanships to reestablish CMA’s position at the bargaining table on reforms to the workers’ compensation system. Last year, partnering with Senator Richard Pan, M.D., CMA sponsored SB 563 to ensure the utilization review program was not providing incentives for denying medically appropriate care. This effort, combined with our continual effort to push for improvements to the system, resulted in our sponsored bill being incorporated into a larger workers’ compensation reform bill, which decreased the usage of prospective utilization review – solidifying the physician’s place in that discussion.
We also turned our eye inward to the health and the future of the profession. Working closely with our colleagues at the California Academy of Family Physicians, the California Primary Care Association and other organizations, we secured a badly-needed investment in our state’s primary care workforce: a $100 million appropriation in the 2016-17 state budget. This appropriation will provide $33 million each year for three years to increase funding for the Song-Brown Program, a competitive grant program that supports primary care residency programs in medically underserved areas. The budget will set aside some portion of this money exclusively for residency programs at clinic-based Teaching Health Centers, including support for the six existing sites as well as for clinics interested in starting new training programs. We believe this augmentation represents one of the biggest investments in the primary care physician workforce the state has ever undertaken.
Then, with the California American College of Emergency Physicians, we co-sponsored legislation to extend the program that donates certain traffic fines to the Maddy Emergency Medical Services Fund, which provides reimbursement to physicians who treat uninsured patients. Finally, CMA ensured that physicians suffering from substance abuse had a credible, viable health and wellness program to ensure that their patients continue to receive the very best care from those impacted physicians.
Our opponents also have the ability to recognize and take advantage of opportunities, resulting in threats that must either be defeated or neutralized depending on the political realities surrounding the particular issue.
Threats to the profession during this legislative session came in the shape of SB 932 (Hernandez) and SB 1033 (Hill). SB 932 sought to put limitations on what may be included in contracts between health care insurers/plans and providers, as well as to implement a new process for approving mergers and acquisitions of health plans and risk-based organizations. Meanwhile, SB 1033 would have required doctors under probation with the Medical Board of California to disclose their probationary status to all patients. Neither measure made it out of their House of Origin.
Once again, we protected patients from undertrained practitioners offering treatment outside of their scope of practice. Nurse practitioners, optometrists, naturopathic doctors and certified nurse midwives — all had their scope expansion efforts decisively defeated.Scope bills on nurse practitioners (SB 323 - Hernandez) and optometrists (SB 622 - Hernandez) were not even brought up for a vote in the Legislature this year due to overwhelming pressure and negative perception of the proposals in the Capitol. Naturopathic doctors (SB 538 - Hueso) and certified nurse midwives (AB 1306 - Burke) were longer fights, with both lasting up until the last hours of the legislative session. Ultimately, however, both bills were defeated by wide margins.
Amid all of these defeats, this year was also a year of great compromises. The majority of the bills we opposed at the start of the year were neutralized through amendments and negotiations during the course of the legislative session.
This year saw the completion of the CURES database negotiations that were begun in 2015. SB 482 (Lara) is a great achievement in mitigating the inevitable tightening of requirements for CURES database use. More work on this issue remains to be done, but much has been achieved through this bill and through building a foundation of cooperation with the Legislature and other stakeholders.
The most contentious negotiation this session was that of AB 72 (Bonta, et. al.), the out-of-network bill signed into law by the Governor. AB 72 is a direct result of our defeat last session of AB 533 (Bonta), which essentially would have extended Medicare rates to all non-participating physicians. CMA defeated AB 533 last year on the last night of session. However, Assemblymember Bonta requested reconsideration, a procedural maneuver that granted him an opportunity to bring up the bill at any point in 2016 for a second vote.
To neutralize the threat of a revote on AB 533, our allies forced Bonta to restart negotiation on out-of-network billing, not only with CMA but also with the legislators as well. Their intervention precipitated the development of the jointly-authored AB 72. The joint authorship of Assemblymembers Wood, Santiago, Maienschein, Gonzalez, Dahle and Bonilla was far more favorable for our association than the prior year’s stakeholder process, which was solely directed by Assemblymember Bonta’s office. The end result is a law that puts to rest the issue of so-called “surprise billing” in a way that preserves the ability of a physician to continue collecting their usual rate (as long as they obtain the consent of the patient), implements a statutory payment structure that borrows significantly from CMA policy and ensures that the statutory payment structure only applies in a narrow set of circumstances.
While the enactment of AB 72 can never be described as favorable, it did present CMA with the opportunity to rise above the negative political constructs and portrayals of physicians conjured up by the health insurer lobby. Through our good faith participation in the AB 72 stakeholder process, CMA once again represented the true nature of physicians delivering care in a complex system. We were able to convey that physicians desperately do not want patients to be financially injured by the profit-driven decisions of health insurers to narrow physician networks so that patients are barred from having a substantive opportunity to utilize their in-network benefits.
Yet again, CMA rose to the occasion, transforming an absolute debacle into an advocacy gateway leading to enhanced network adequacy standards and allowing physicians a means to continue collecting their normal rate. Our actions also weakened the narrative weaponry available to health insurers. Surprise billing, or balance billing, was the primary “white hat” issue for health insurers. With the introduction of AB 533, they sought to exchange that “white hat” issue for a substantial financial windfall. With the passage of AB 72, the insurers have lost that issue in a manner that could see the overall physician compensation increase over time and stricter oversight of their networks.
Change Is Happening
The question is whether CMA will continue this trend of rising above a turbulent political environment and marketplace to lead California from uncertainty to clarity. No longer can organized medicine maintain an overly defensive posture, hoping and working to simply maintain the status quo or to get things back to the way they used to be; such a position is unrealistic and will lead to decisive losses in the near future.
Change is happening, and change will continue to happen. CMA’s charge must be to look into the future and act boldly to shape the world of health care in a way that is most favorable for all physicians and their patients.
CMA’s leadership challenge is not new. The physician leaders and staff that set the course of this organization had the same duty. I submit to you the same call to action as CMA’s former Chief Lobbyist Steve Thompson:
“Crisis… is an opportunity for leadership. It’s an opportunity for the CMA to take the lead in providing solutions to the myriad problems facing health care today. The challenge ahead is to know what solutions to propose. But, if CMA does not lead in problem solving, that role will be filled by others who are far less concerned with what the future holds for physicians and patients.”
As we embrace this challenge, we must recognize that sometimes it is impossible to find complete agreement — what might help one physician might be less favorable to another. But we are organized medicine. We cannot allow rifts to seep outside of our House. We cannot give into the temptation to tear down what has been built. Our enemies are waiting and counting on division within the House of Medicine to create fractures so they may exploit the harmful opportunities that would result.
We rise today because we were unified yesterday. We will rise tomorrow, because we reaffirmed our bond today.
For more details of the major bills that CMA followed this year, see www.cal.md/legwrap2016.