A significant win this session was the repeal of the sunset of the 2% provider tax, which is set at a new, ongoing level of 1.8%. The additional revenue from the tax opened opportunities in the budget to make investments in many programs that will improve the lives of Minnesotans, including help for low-income families, improved access to health care for people with disabilities, and funding to build out the state’s mental health system.
Senate Republicans had initially proposed significant cuts to services in order to balance their budget without continuing the provider tax. Those cuts included a complete elimination of the Child Care Assistance Program (CCAP), enrollment caps on some medical assistance waivers, and the elimination of all dental coverage for adults on medical assistance. None of these cuts made it into the final bill.
Extends the reinsurance program for two years
Republicans fought hard to block all of the health care reforms proposed by the governor in favor of continuing their reinsurance program. They succeeded in getting a two-year extension of the program, the result of which is that Minnesotans will continue to face the same affordability concerns that exist under the current reinsurance program, and any real market reforms are pushed further down the road (See Commerce for more information).
$100 increase in the MFIP grant
Families on the Minnesota Family Investment Program (MFIP) will see a $100 increase in their monthly cash benefit. This is the first increase since 1986.
CCAP program integrity
Inflammatory allegations of fraud in the CCAP program brought it under the microscope this year. Although those claims were not substantiated, the governor proposed several program integrity measures and improvements to make sure the Department of Human Services has the tools it needs to ensure all program dollars are going to the families who need them. The legislation also adds 10 new FTEs to the DHS Office of the Inspector General.
The budget funds the creation of a Child Welfare Training Academy that will provide a uniform, foundational curriculum for all child welfare workers in the state. Better training will reduce turnover and burnout and will set county workers up for success. Also included is an expansion of the American Indian Child Welfare Initiative that moves statutory authority for child welfare services from counties to tribal governments. The funding will support current services and expand the Initiative to two more tribes.
15% Reduction in TEFRA parental fees
TEFRA is medical assistance coverage for children under 19 that have a disability and need a level of care similar to that provided in a hospital or skilled nursing facility. Only the child’s income is counted under the TEFRA option, but parents must pay a fee to access the program based on a sliding income scale.
Elimination of the spenddown in FY2023
People with disabilities who have income too high to qualify for medical assistance are currently required to spend down a portion of their income on health care expenses in order to access the program. The current spenddown leaves Minnesotans with disabilities with monthly income equal to just 81% of the federal poverty guideline, well below the income threshold set for people who do not have disabilities. The spenddown is eliminated starting in FY2023.
DWRS competitive workforce factor
A competitive workforce factor starting at 4.7% is added to the disability waiver rate system (DWRS) to help providers of services for people with disabilities pay their staff higher wages. This modification was designed to help reverse the 7% rate reduction experienced by some providers after the state stopped paying for prior rate increases when the federal government declined to match the state’s investments, and it makes wages for direct support professionals more competitive.
State funding is extended to replace lost federal funding for children’s residential facilities that would otherwise be forced to close, and the state’s Psychiatric Residential Treatment Facility bed capacity for children is increased by 150 beds. Funding is also provided for adult mental health grants for regional mobile mental health crisis response teams throughout the state.
Comprehensive suicide prevention
A multi-faceted proposal on suicide prevention will be implemented that includes funding for a state-based suicide prevention hotline. The previous state-based hotline shut down last year due to lack of funding.
School-linked mental health grants
Very limited funding for school-linked mental health grants of $1.2 million is included in the first biennium, with increased funding of $9.6 million in FY2022-23.
Statewide Tobacco Cessation Quitline
The Department of Health will contract for statewide tobacco cessation services to replace QUITPLAN Services when it sunsets in March 2020. QUITPLAN is operated by ClearWay MN, a life-limited organization funded from the tobacco settlement.
Arbitrary reduction in the growth trend for managed care
Senate Republicans included a proposal in their HHS budget to find savings by arbitrarily reducing the amount of money health insurance companies receive for providing health care through the state’s public programs. The Senate budget reduced funding by 1.6%, despite a lack of evidence that the proposal was fiscally sound.
Any reduction in rates must align with actual cost data or the federal government will not approve it. Due to opposition from DFL lawmakers and the governor, the final agreement includes a reduction of just 0.8%, and it requires that unused funding from the premium security account, used to fund the reinsurance program, be made available to back up the proposal.
Blue Ribbon Commission
The commission is created to look for $100 million in savings from within the HHS budget. The full $100 million in savings is booked in FY2022-23. Funds will be transferred from the budget reserve if the savings cannot be found.
New fees on opiate manufacturers
Historic legislation that generates funding to combat the opioid epidemic by raising fees on manufacturers of opiates finally made it across the finish line this year. The Senate passed the legislation in a decisive 60-3 vote in the final hours of the regular session. After the Senate passed similar legislation last year, the Republican-led House refused to take up the bill, leaving Minnesotans to wait another year for this desperately needed funding. With new DFL leadership in the House this year, the legislation was given new life.
The annual registration fee for all pharmaceutical manufacturers and wholesale distributors is raised to at least $5,000 each year, increasing to $250,000 for those selling the highest quantities of opiates in Minnesota. These new fees will bring in over $20 million each year to fund a comprehensive treatment and prevention effort that will undoubtedly save lives, and it amounts to just a sliver of the skyrocketing profits made by the pharmaceutical companies. Advocates argue that drug manufacturers need to pay their fair share for the harm their products have caused and alleviate some of the financial burden borne almost entirely by taxpayers to address this crisis.
Unfortunately, the bill returned from conference committee without removing the provision to sunset the highest fees in the bill that was included in the Senate proposal and opposed by DFL members. However, the sunset was negotiated to occur at a later date and after a higher amount of money is collected. The sunset is initiated after at least five years and whenever Minnesota receives a combined total of $250 million from any of the active litigation against drug manufacturers or fees collected under the legislation.
The legislation also includes provisions like authorizing health care directives that allow patients to state they do not want to be prescribed opiates, requiring prescribers to check the Prescription Monitoring Program database before prescribing controlled substances, and limiting the quantity of opiates prescribed for acute pain, like pain after an injury or surgery, to a 7-day supply for adults and a 5-day supply for children. Doctors can still write prescriptions for more than the limit if they believe it is necessary, and prescriptions are not limited for patients experiencing chronic pain. (HF 400)
Pharmacy Benefit Managers (PBMs)
Bipartisan legislation to license key players in the pharmaceutical industry, called pharmacy benefit managers (PBMs), unanimously passed the Senate floor on a 67-0 vote in April and was signed into law in May. The legislation authorizes the Minnesota Department of Commerce to license and regulate PBMs operating in Minnesota and requires the companies to disclose certain information about how they conduct business, which will be shared with Minnesotans through public reports.
PBMs contract with health plans to administer their prescription drug benefits. They can decide which pharmacies are in a plan’s network, design formularies and preferred drug lists, determine patient co-pays, and pay pharmacy claims for insurance companies. The public and government regulators currently have very little insight into how PBMs operate and how their practices affect the prices of prescription drugs.
Critics of PBMs point to the use of rebates as a reason why the pharmaceutical industry may have a disincentive to keep prices low. PBMs negotiate rebates from the manufacturers in return for agreeing to add or restrict medications on insurance company formularies. Manufacturers can keep raising prices and steering customers to certain medications while PBMs benefit by keeping a portion of the rebates they secure. Licensing PBMs will shine a light on this extremely complex system. It is a crucial step toward reigning in high drug prices.
Licensure makes a strong statement that Minnesotans deserve more transparency at a time when the pharmaceutical industry keeps pointing their fingers at each other over high costs while prescription drugs prices only rise higher and higher. More information will help everyone, from lawmakers to patients, make more informed decisions that will make health care more affordable and put patients first. (SF 278)
Licensing assisted living facilities and protecting seniors
After failing last session to pass critical reforms to protect seniors and vulnerable adults, legislation licensing assisted living facilities and strengthening consumer protections passed in the final days of the regular session. The legislation represents an agreement between consumer advocacy organizations and industry representatives completed after several months spent developing a new system of regulatory oversight that could garner broad support.
This legislation was sparked by a series of horrific stories of abuse and neglect of seniors in assisted living facilities profiled in the media, and the state has continued to receive hundreds of new reports each week in the absence of these reforms. Minnesota is currently the only state in the country where assisted living facilities are not required to be licensed.
The legislation includes a licensing framework that authorizes the Department of Health (MDH) to inspect and fine facilities for violations; includes clarification and strengthening of the rights of individuals living in assisted living settings; and sets new requirements and protections for electronic monitoring (also known as granny cams). It also contains full funding to implement the reforms, including money for licensing and enforcement staff and systems upgrades at MDH and Department of Human Services, 17 new positions at the Ombudsman for Long-Term Care, and new data analysis.
The consumer protections in the bill will give seniors and their families the information and tools they need to receive safe and quality care, including a new assisted living bill of rights, prohibitions on retaliation, and stronger protections against service terminations and evictions that can uproot seniors at their most vulnerable and leave families scrambling. Several DFL senators are concerned that some protections were not included, like the ability to enforce rights through civil action and allowing lawsuits to continue after the person at the center of the lawsuit has died. These ideas are likely to be brought forward in the future.
This legislation is a significant accomplishment; however, the failure of last year’s bill under Republican leadership in the House and Senate meant seniors had to wait an additional year for licensure and the crucial protections in this legislation. (HF 90)
Emergency medication administration
The Emergency Medical Services Regulatory Board is directed to propose guidelines and legislative changes required for EMTs and paramedics to assist a patient with a rare, life-threatening medical condition by administering a patient’s own prescription medication in an emergency.
This legislation was brought forward after two children with rare diseases discovered they could not have an emergency responder legally administer their life-saving medicine during a medical crisis. Under current law, patients generally have to wait for emergency transport to a hospital and then wait for the hospital to dispense a medication from the hospital’s own supply. (SF 153)
Reestablishing the parent-child relationship
New legislation allows a parent whose parental rights have been terminated to petition the court to reestablish a legal parent and child relationship if certain conditions are met, including that the parent has corrected the conditions that led to the termination of rights, the child has been in foster care for at least four years, and the parent’s rights were not terminated due to egregious harm to the child.
County attorneys are currently the only people who can file these petitions, and their decisions are not subject to appeal. This means children are all too often stuck in the foster care system for many years despite tremendous improvements their parents have made. The legislation will open up the petition process to parents who have worked tirelessly towards rehabilitation, particularly for parents experiencing challenges with mental health and substance use disorder, where the road to recovery may take significant time. (HF 554)
Rare disease advisory council
The Board of Regents at the University of Minnesota will create an advisory council on rare diseases to make recommendations on quality and access to treatment and services for people with rare diseases. Patients and families face challenges raising awareness, accessing resources, and managing care without adequate supports. The council will bring together advocates, experts, and specialists to focus on improving the lives of people with rare diseases. (SF 973)
Facility fee disclosure
Health care facilities are now required to provide notice to patients that a facility fee may be charged prior to delivering non-emergency medical services; notice of the fee must be posted prominently in the facility and online. Facility fees are extra fees that can be charged under federal law by some clinics that are owned by hospitals. These fees often come as a surprise and can significantly increase out-of-pocket costs for patients for even simple or routine visits to the doctor. (SF 131)
DFL members have been pushing to reinstate the ban on for-profit HMOs in Minnesota despite strong Republican opposition. After a health insurer began transferring millions of dollars to a for-profit subsidiary, lawmakers on both sides started looking for a solution to prevent further transfers. A compromise was developed that extends the moratorium on nonprofit conversions, limits asset transfers to the lesser of 10% of net assets or $50 million, and requires nonprofit health insurers to use their net earnings for the provision of health care for Minnesotans. This agreement is likely to be revisited next session.
Medical cannabis program changes
Changes to the medical cannabis program include the authorization of the use of hemp purchased from licensed Minnesota hemp growers, the use of telemedicine to recertify patients, allowing manufacturers to distribute a 90-day supply rather than a 30-day supply of cannabis products, and doubling the number of distribution sites from 4 to 8.
PROVISIONS THAT DID NOT PASS
Conversion therapy ban
After the Republican Senate refused to discuss a bill to ban mental health professionals from engaging in conversion therapy with minor clients or vulnerable adults, the DFL offered an amendment to add it to the health and human services omnibus bill. Unfortunately, despite some Republican support and clear evidence of the irreparable damage this type of “therapy” can do to young people, the amendment failed. Republicans also succeeded in keeping the language out of the final HHS agreement.
Two proposals to change the way the state treats marijuana failed to become law this year. The bipartisan effort to move the drug from Schedule 1 to Schedule 2 in the Minnesota Controlled Substances Act failed. Schedule 1 drugs typically have a high potential for abuse and no accepted medical use while Schedule 2 drugs do have accepted medical use. The current scheduling of marijuana is in direct conflict with the existence of the state’s medical cannabis program.
An effort to add raw cannabis to the medical cannabis program also failed. Supporters said allowing raw cannabis could lower the cost of the program for patients; the proposal would not have allowed patients to smoke the cannabis (See Judiciary for information on the effort to legalize recreational use).
Alec Smith Insulin Act
The Alec Smith Insulin Act to establish an emergency insulin program failed to become law this year, despite broad support. The exorbitant cost of insulin has become a life-threatening barrier to diabetics around the country, and Minnesota had an opportunity to make emergency insulin available through a new fee on insulin manufacturers. The program would provide emergency insulin to those that cannot afford the drug. Despite publicly stating support and amending the program onto the Senate HHS bill on the floor in a unanimous vote, Republican leaders failed to include it in the final HHS budget agreement passed during the special session.
A bill to raise the age to purchase tobacco products to 21 did not make it across the finish line this session despite support from dozens of health and patient advocacy organizations. Cities and states across the political spectrum have been voting to raise the age all across the country. Numerous studies and surveys lay out a strong case for raising the age to purchase tobacco statewide. Advocates assert that fewer young people would start smoking, making it a smart public health initiative.
The governor’s ONECare MN proposal includes a multipronged approach to create comprehensive health coverage options, encourage stability in the individual market, provide consumer choice, address rising health-care costs, and improve the health care experience for all Minnesotans.
ONECare allows Minnesotans statewide to purchase a platinum-level buy-in product offered by the Minnesota Department of Human Services in Minnesota’s individual market. This option would have a provider network and benefit set similar to the MinnesotaCare program, including dental and vision benefits and behavioral health services. ONECare options would also be available as silver- and gold-level buy-in products in any region of the state where the individual market fails to provide options. The proposal also includes reforms to dental and prescription drug benefits in Minnesota’s public health care programs that would improve access and affordability.
20-week abortion ban
A proposal to ban abortion after 20 weeks failed this session. It would have made violations by physicians a felony and limited exceptions to a narrow set of ill-defined reasons. Civil remedies could be brought by a significant list of people related to the mother as well as health care providers, county attorneys, and the attorney general.
The proposal faced significant opposition from DFL Senators and several medical organizations. Governor Dayton vetoed the same bill in 2011, calling the criminal penalties unconscionable and asserting the bill infringed on a woman’s basic right to health and safety. This legislation uses intimidation and fear to prevent physicians from delivering care that is in the best interest of their patients. It does not reflect Minnesota’s standard of high-quality, comprehensive care. Medically appropriate care is best determined between medical experts and patients, not politicians. Every pregnancy is different, and adequate medical options should be available for doctors and all Minnesota families so that they may determine what is best for them.