2019 ISSUE #7
Issue 7, 5/29/2019
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Articles in This Issue:
- GOVERNOR FINISHES SIGNING BILLS
- GOVERNOR VETOES MEDICAL CANNIBIDIOL CHANGES
- SECOND CHANCE AT BECOMING LAW: THERE'S ALWAYS 2020
- FISCAL YEAR 2020 BUDGET RECAP
- LEGISLATORS LOOK AT OTHER OFFICES
- SUMMER ADVOCACY RESOURCES
GOVERNOR FINISHES SIGNING BILLS
With just minutes to spare before the three-day Memorial Day weekend, Governor Kim Reynolds took final action on the remaining bills sent to her this legislative session, including vetoing a bill that expanded access to medical cannabidiol that contains higher levels of the ingredient that gets people high (THC) and using her line-item veto authority to strip out language in a budget bill that would have limited the Attorney General’s ability to sign onto national lawsuits (like the class action lawsuit against opioid manufacturers Attorney General Tom Miller recently signed onto).
Legislators introduced 2,065 bills and resolutions during the 104-day legislative session, but only 167 of those made it to the Governor’s desk. That means bills introduced this year had an 8% chance of becoming law, well below the historical norm of 10-13%. The following bills were passed by the Legislature and signed into law by the Governor this year:
- Requires that all counties use the postal service bar code system to track absentee ballots by October 1, 2020, fixing issues that occurred in one very close race that ended up with 29 absentee ballots going uncounted in 2018 (HF 692). Beginning with the 2020 general election, county auditors will be able to track a mailed absentee ballot and use either date received, postmark, or the bar code system to verify when the ballot entered the system. There are other election law changes in the bill, but they are corrective or not controversial.
- Closed loopholes in dependent adult abuseto include personal degradation (HF 569) and financial exploitation even if the person committing it doesn’t profit personally or financially (HF 323). Under these new laws, a caregiver that says or does something (including taking or distributing photos or videos) that is intended to shame, degrade, humiliate, or attack the person’s dignity could be charged with dependent adult abuse. Likewise, a caregiver does not have to profit financially or personally in order to be charged with financial exploitation.
- Updated Iowa’s guardianship laws, based on the recommendations of the Iowa Supreme Court’s Guardianship and Conservatorship Reform Task Force (HF 610& HF 591). Among the many changes in these bills, guardians and conservators must go through background checks, including child abuse, dependent adult, and sex offender registry checks. In addition, a petition for a guardianship must explain why there is no less restrictive option available, and the court is allowed to order its own evaluation of decision-making capacity.
- Balanced the rights of property owners and service animal owners(SF 341). There has been a lot of controversy nationally over therapy pets vs. service animals. Iowans with a need for properly trained service and assistance animals have seen their rights violated, while landlords have had trouble figuring out when it’s appropriate to waive pet policies. Under this new law, landlords would not be able to charge additional fees or put additional restrictions in a lease for service or assistance animals, but renters would be required to show proof that they need the service animal and that the service animal is property trained (rules around this will be written by the Iowa Civil Rights Commission). Lying about the need for a service/assistance animal, or about the animal’s training, could result in a fine. In addition, renters would be responsible for property damage done by their service animals.
- Changed Iowa Civil Rights Law to specifically state that it does not guarantee the right for tax-supported gender reassignment surgery for Iowans identifying as transgender, including Medicaid payment for such surgeries (HF 766).
- Added a few new requirements for the Medicaid managed care system (HF 766), but didn’t scratch the surface of issues that were addressed in the 12 other bills introduced to address concerns with the managed care system. Legislators will now have to be notified within 30 days of any MCO contract changes and the state Medicaid office (IME) will now be required to develop and use a uniform prior authorization form and process by October 1, 2019. IME is also to look into the development of a single electronic portal for submitting prior authorizations. The state was also given the authority to assess “liquidated damages” if MCOs don’t fix prior authorization, claims payment system, and provider credentialing issues. Liquidated damages are simply penalties that are outlined by the MCO-IME contract.
- Eliminated the monthly cap for individuals eligible for the Medicaid Brain Injury Waiver (HF 570), getting rid of the unnecessary paperwork to request an exception to policy for those needing to exceed the $3,013.08 monthly maximum. This cap has not been raised since it was put into place in 1996. Medicaid has been approving all exceptions to policy, so this change just ends the extra step individuals with brain injuries must take to get the services they need.
- Created the framework for a regionally-coordinated children’s mental health system, including core service expectations and common eligibility requirements (HF 690). A complete review of this bill can be found in our Issue #3, or a staff analysis here. Regions are expected to hire or designate an existing staff person to take the lead in developing the plan and timeline to build-out children’s core services, but no additional funding was allocated for this. Likewise, there is no funding in the bill (or in the budgets passed this year) to pay for these core services. Funding was included for the state to eliminate the children’s mental health waiver waiting list ($1.2 million), add a children’s crisis hotline to the existing statewide adult crisis line ($306,000), manage the children’s system board ($300,000), and provide schools and teachers with resources for early identification/intervention ($2.1 million for Area Education Agencies).
- Allowed regions to keep more money in reserves while they are developing adult and children’s core mental health and disability services, up to 40% until July 1, 2023 (HF 691). Another bill (HF 766) allows the Polk County Mental Health & Disability Services Region to use other county funds to cover shortfalls in its MH/DS budget. Without this, the region would not have enough money available to sustain core services. This does not address the budget shortfalls that Polk or Eastern Iowa MH/DS Regions are facing next year in fiscal year 2021, or a permanent funding solution that counties and advocates have requested every year since the 2015 redesign.
GOVERNOR VETOES MEDICAL CANNIBIDIOL CHANGES
Advocates for the expanded use of medical cannabidiol (CBD) asked legislators to pass a bill that gives Iowans with painful conditions more flexibility in finding the right treatment. Iowa’s program currently allows a physician to authorize use of CBD for serious medical conditions in order to control pain and seizures. The state’s Medical Cannibidiol Board, which includes patients and physicians, recommended several changes to Iowa law:
- Allowing physician assistants and nurse practitioners to authorize use (a rural access issue).
- Allowing dispensaries to hire pharmacists and pharmacy techs.
- Allowing people with felony convictions to access CBD for qualifying medical conditions.
- Tasking the Department of Public Health to collect and evaluate data on patient use, including clinical outcomes and quality of life improvements.
- Creating more flexibility in dispensing CBD by allowing up to 4.5 grams of THC (the psychoactive ingredient in the cannabis plant that gets people high) to be dispensed over a 90-day period. Currently, Iowa law limits the per-dose level of THC to 3%, which makes the medication difficult to develop and increases costs to the patient.
The bill that ended up passing the Iowa Legislature (HF 732) made the first four changes, but allowed patients to access a 90-day supply of CBD that contains up to 25 grams of THC. The bill passed with broad bipartisan support, but treatment providers, the CBD Board, and the medical community expressed concern about the THC level change, citing data that shows 100 mg of THC is considered to be a “recreational” dose of THC, and 20 mg is considered to be psychoactive (i.e. make people “high”). The new legislatively-approved limit (25 grams over 90 days) would allow a daily level of 277 mg (more than double what is considered recreational).
Ultimately, the Governor decided to veto the bill and urged caution in moving forward. “Since our program began, I have heard countless stories of relief and remarkable improvements that CBD has offered Iowans. And I support our program and efforts to strengthen and improve the program, so that it continues to be safe, rational and compassionate medical CBD program,” expressed Governor Reynolds in her veto message. “But unfortunately, the bill would also remove the three percent limit on THC in medical CBD products and replace it with a limit of 25 grams of THC per 90-day period. This change was not recommended by the Board. And if approved, it would drastically expand Iowa’s medical CBD program far beyond its original scope…and could open the door to significant unintended consequences to the health and safety of Iowans.”
The Governor urged advocates, treatment providers, medical community, legislators, and the CBD board to work together to develop a strong program that meets the needs of patients without putting the public health of Iowans at risk. Already several legislators, including pharmacist Rep. John Forbes (D-Urbandale) and bill sponsor Sen. Brad Zaun (R-Urbandale), have said they will make passage of a CBD bill a priority in 2020. Some Democrats have called for a special session to override the Governor’s veto, but Iowa lawmakers have rarely done this.
SECOND CHANCE AT BECOMING LAW: THERE'S ALWAYS 2020
If a bill you were watching didn’t make it through the process this year, never fear, they have a second chance in 2020. Bills that didn’t make it through the process this year are eligible for debate in the 2020 session, but you’ll have to do some advocacy over the summer to make that happen. Here are a few of those bills:
- Consumer protections for telecoil assistive devices (HF 120) and requiring insurance coverage for children’s hearing aids, including ear molds and audiological habilitation or rehabilitation (HF 399).
- More significant managed care protections and stronger oversight, or an end to managed care entirely (SF 143, SF 156, SF 168, SF 211, SF 358, SF 420, SF 468, HF 135, HF 555, HF 617, HF 618, SSB 1234).
- Encourage same-day multiple therapy services to children by eliminating reimbursement reductions (SF 147). Medicaid currently reduces total reimbursement if therapy services, physical therapy services, occupational therapy services, and speech/hearing/language disorder services are delivered at same patient visit to a child.
- Medicaid and private insurance coverage for medically-required food consumed through feeding tube(SF 453) and prohibiting health care plans from requiring medically-stable patients who use a prescribed drug to switch to a health plan that does not include the prescribed drug (SF 489).
- Helping Iowans with chronic conditions, disabilities, or age-related mobility issues to remain in their own homes by providing home modification grants (SF 190, SF 269) or tax breaks (HF 527). Enhanced penalties for contractor fraud to protect those that are getting work done on their home didn’t pass either (SF 461, HF 602).
- Direct care professional recruitment and retention by eliminating state taxes on income earned providing services to individuals with disabilities (SF 41, SSB 1185).
- Review Iowa’s special education system, including requirements and outcomes for students with individualized education plans (SF 316).
- Enhanced high school health education programming to include mental health awareness, coping skills, and suicide prevention (SF 376).
- Community engagement requirements that would require Iowans work, volunteer, or go to school for a minimum number of hours in order to maintain eligibility for Medicaid and other public programs (SF 334, SF 434, SF 538).
- Changes to the state’s medical cannabidiol program in the wake of the Governor’s veto (HF 221, SF 71, SF 77, SF 78, SF 501).
If you care about these issues, or other issues that were not discussed this year, start talking to your legislators now. Ask your State Representative and State Senator to meet you at a local coffee shop, community center, or library. Bring others that care about the issue - there is power in numbers and you won’t be as nervous. Ask them to sponsor a bill and ask if they have other advice for you. Contact your legislators at home now (they’re no longer at the Capitol). Contact information is in our Guide here.
FISCAL YEAR 2020 BUDGET RECAP
It took two weeks to work out an agreement on the last bill standing (Health and Human Services - HF 766) but it finally passed on the last day of the legislative session. Because of the way amendments were done in the House and Senate, the minority party was not able to offer amendments (including several that would have addressed Medicaid managed care and provider rates). This was not done on other budget bills, although some saw debate restricted to a “time certain” (meaning debate was cut off at a specific time). Some legislators say this was done in order to wrap session up on time. Others say it was done to limit debate on hot-button issues. Still others say it was to protect legislators from having recorded votes on certain topics. Here’s a quick review of what’s in the budget bills passed this year:
- Adds $150.3 million to the current year's budget (called a supplemental). Almost all of this increase goes to the managed care organization (MCO) contracts. The current budget year ends June 30.
- Spends $1.937 billion for the next budget year, which begins July 1, 2019. This is $34.9 million less than the current year (because the Legislature didn't add the $150.3 million supplemental to the base).
- Includes new $306,000 appropriation to add a children’s behavioral health component to the Your Life Iowa referral service, hotline, and website. In addition, $32,000 is transferred from DHS to help offset the costs of this hotline. This makes both adult and children crisis service information available through a single portal.
- Eliminates $191,000 funding for the Iowa Caregivers Association to address direct care workforce challenges and redirects it for “health care and public health workforce initiatives.” Several legislators promised advocates these funds would still be used for direct care workforce initiatives, but the language does not require it.
- Adds $400,000 to create and train four psychiatric residents per year to provide mental health services to underserved areas of the state and adds $150,000 for psychiatric training for physician assistants and nurse practitioners through Des Moines University.
- No change in funding for the epilepsy foundation but includes language that would require the entire amount of the funds be allocated on July 1 (organizations typically get paid quarterly or monthly after filing reports; this would continue to require reports but the money would be provided upfront).
- Increases the Children’s Health Insurance Program (hawk-I) by $12.3 million to replace lost federal funds and nursing home reimbursement (called rebasing) by $23.4 million.
- Adds $1.2 million to eliminate the children’s mental health waiver waiting list, $211,332 for Assertive Community Treatment (ACT) team reimbursement, and $1 million for community living provider tiered rates (distributed equally among all tiers).
- No change in funding for Aging & Disability Resource Centers, audiological services and hearing aids to children, youth suicide prevention and a survey of children who experienced adverse childhood experiences (ACEs), medically necessary foods for those with metabolic conditions, brain injury services and training/recruitment of providers, child health specialty clinics, regional autism assistance program, Prevent Blindness Iowa, Des Moines University training of doctors to identify and treat patients with mental health needs, standardized assessments for persons with MI/ID/DD/BI, Medicaid oversight, Tanager Place support services to children with autism spectrum disorder, State Supplementary Assistance (SSA), State Resource Centers, technical assistance to HCBS waiver habilitation providers, family support subsidy, and ABLE account support.
- Directs the Directors of the Departments of Public Health and Human Services to develop recommendations for enhanced delivery of co-occurring (mental health/substance use) conditions services, examine current service delivery system to identify opportunities to reduce administrative burden on departments and providers, evaluate the use of integrated helpline and website for data collection and sharing outcomes, and create a structure for ongoing collaboration (five-year plan and report due 12/15/19).
- Eliminates boards and commissions that are no longer functioning or been replaced by other groups, including the Children’s Mental Health Waiver Implementation Committee and the MH/DS Property Tax Relief Fund Risk Pool.
- Changes the voting members on the 50-plus member Medical Assistance Advisory Council (MAAC). The bill eliminates the elected “Executive Council” and replaces it with 10 voting members (5 professional/business entity representatives elected by the entire membership and all five of the Governor-appointed members). All current MAAC members will become non-voting members. Changes the ten Governor-appointed public members to five, of which at least one needs to be receiving Medicaid services. There are currently no vacancies for public members on this board, but if you are interested in serving on other boards, here is a list of vacancies.
- Expands Medicaid coverage to pregnant women who have legal protection status (that is, refugees in the five-year window before they can apply for citizenship). Federal law requires state Medicaid programs to pay for the costs associated with these births, but not prenatal care for the women before birth. Legislators found that it is cheaper to cover the care of these women while pregnant, so they can have healthy babies - than pay for the costs of one child ending up in the neontal intensive care unit with preventable conditions.
- Changes Iowa Civil Rights Law to state that it does not provide the right to tax-supported gender reassignment surgery or any other reconstructive surgery for transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder (effective 5/24/19). This was never discussed as a bill this year, but it was added after the Iowa Supreme Court ruled (in early March) Medicaid should cover the costs of such surgery. You can read that ruling here. Advocates are likely to appeal this now that it has been signed.
- Makes technical changes to the children’s behavioral health system state board (allows the MH/DS Commission representative to be appointed by the Commission, instead of the Governor).
- New funding to expand access to high speed Internet into rural areas of the state ($5 million), increase prosecution of insurance fraud ($220,000), school-based children's mental health resources and training through AEAs ($2.1 million), and for Best Buddies to create opportunities for students with intellectual and developmental disabilities ($25,000).
- Small increases for the Department for the Blind ($79,877), educational services for the blind and visually impaired ($167,000), and the Iowa School for the Deaf ($302,962). No change in funding for Vocational Rehabilitation ($5.7 million), Entrepreneurs with Disabilities ($138,506), Centers for Independent Living ($86,457), and independent living services ($84,823).
You can read more about each budget here.
LEGISLATORS LOOK AT OTHER OFFICES
The 2020 general election is more than a year away, but that’s not stopping legislators from considering their options. Some are considering higher office, appointed office, or retirement. Here’s a list of what we know so far:
US Rep. Dave Loebsack (D-Iowa City) announced he will not run for Congress again in Iowa’s 2nd Congressional District. Rep. Loebsack was first elected in 2006. Former Democratic Iowa Senator Rita Hart of Clinton has announced she will run. Hart was the running mate of gubernatorial candidate Fred Hubbell in 2018, and is a family farmer. Osceola Mayor Thomas Kedley has announced his will run as a Republican for the seat. I’m sure there will be more to come here.
With Rep. Andy McKean’s end-of-session switch to Democrat, committee assignments will be shuffled around. If Rep. Lisa Heddens is appointed to the Story County Board of Supervisors, a new Ames area legislator will be elected to finish out her two-year term.
SUMMER ADVOCACY RESOURCES
Review the bills that passed and stalled in the Legislature this year, see when your legislators and other elected officials are hosting public meetings in your area, or review your advocacy skills using the resources below.
- Click here for Bill Tracker.
- Click here for Public Forums list.
- Click here for Guide to the Iowa Legislature (updated 5/28/19).
- Click here for Advocacy Toolkit.