ssion Enters Final Weeks*
*maybe, no guarantees.
With just two full weeks left before legislative per diems end, legislators are clearing calendars and turning attention toward budgets. April 17 is the 100
day of the 2018 Legislative Session, the unofficial “last day.” Of course, legislators can (and usually do) go longer, but they do so on their own dime. That’s usually powerful incentive to wrap up as close to the expense-ending deadline.
That leaves only 10 working days before April 17 and legislators have 10 budget bills to pass and there are still plenty of tough policy debates ahead. There are
eligible for debate right now in the House, and
on the Senate calendar. Still on calendars waiting for debate are:
- Sanctuary Cities
- Abortion ban after fetal heartbeat detected
- DRAM shop reform (capping liability of bars/restaurants for over-serving drunk drivers)
- Opioid Epidemic Response
- School lunch shaming ban
- Traffic camera ban
Even though the remaining 97 bills may not look controversial, even seemingly boring and mundane bills can heat up and take up valuable debate time. Take the exchanges this week over
House File 2297
, the boiler and unfired steam pressure vehicle inspection bill. This bill got into “hot water” after an Iowa family was killed in Mexico of a suspected faulty hot water heater. The bill, which changes inspection requirements, became, well, heated.
Rep. Rich Taylor (D-Mt. Pleasant) has expertise in this area (he does HVAC, refrigeration, and electrical work in his “real life”). He relayed a personal story involving his brother and an exploding water heater. While the incident didn’t end up tragic like the Creston family, it did blow out the back of the house (and blew his brother into the back yard).
“That is serious stuff ladies and gentlemen of the Senate…where did this come from? Why are we running it?” said Sen. Bill Dotzler (D-Waterloo). “There will come a day when your name is going to be on this, and you’re gonna wish that you never supported it…Every single person that knows a thing about this is a no, but the Iowa Legislature knows better? C’mon.”
Sen. Mark Chelgren (R-Ottumwa) proceeded to explain the science behind exploding hot water heaters, doing spontaneous math that included predicting the atmospheric pressure in Iowa and the difference between the pressure in a boiler (you know, British Thermal Unit differentials and the like). I won’t go on, but you get the picture. An equally contentious debate followed, dealing with “mechanics liens.”
The moral of the story – even “easy” bills may become too hard of a lift if they take up too much debate time. And the clock could just run out on some of the more emotionally or politically charged issues. The only thing we can say with certainty is that nothing but the passage of budgets is certain. It’s the only thing left that legislators
TAXES & BUDGETS
I don’t know if it's a coincidence, but lawmakers are talking about tax cuts this year, and the session is set to adjourn on April 17, which happens to be Tax Day 2018 (the day your federal taxes are due). While the only thing legislators have to do this year is pass a budget, they cannot do that until a decision is made on taxes. More specifically, tax cuts. Here’s a quick review on where we’re at with taxes & budgets:
- Current Year Budget Cut (aka "Deappropriation): The Legislature passed, and the Governor signed, a bill (Senate File 2117) that cuts $23.3 million in spending from the current state budget, and stops another $20 million from being used for business tax credits. These cuts include $660,000 from public health programs and $4.3 million from DHS. The DHS cuts cannot be made in a way that cuts Medicaid benefits, but may impact Medicaid in other ways. IDPH cuts will reduce the substance use block grant by $180,000, local boards of public health by $235,000, and the rest will likely be an across the board cut to contracts (IDPH has said that they will use money they “withhold” from contracts, so it shouldn’t impact current planning for grantees). We do not yet know what impact, if any, this will have on the post-doc internship program funded through IDPH. We do know that IDPH has said that while the amount of the cuts may be annualized, the way the cuts are made will not be (i.e they may choose to allocate funding differently next year). The cuts need to be made in the last three months of this fiscal year (before June 30, 2018).] Most departments are given total discretion on where to make the cuts. You can read more about these cuts here.
- Next Year's Budget & Tax Cuts: People always think that when one party controls the Legislature and the Governor's Office, negotiations are a breeze. Not so. Legislative leaders have been working on budgets for next year (fiscal year 2019, which begins July 1). However, the budget is complicated this year by an effort to cut taxes. The Iowa Senate wants to cut taxes by $1.7 billion; the Governor recommended $1 billion. The Senate plan cuts corporate taxes; the Governor calls for a task force review of corporate taxes before making changes. Cutting taxes means less money is available for budgets. So, it is impossible to come up with a budget until there is a decision on tax cuts. There is apparently light at the end of the tunnel. House Speaker Linda Upmeyer and Senate President Charles Schneider agreed that next year’s budget will be more than the $7.25 billion currently being spent (after deappropriations). “I anticipate it will be a little bit bigger, yes,” Upmeyer told reporters this week. “We will fund the priorities of Iowa. That’s not to say that nobody might move backwards, they may.” Schneider added, "Our numbers are very close to one another. There’s not a whole lot of daylight between the two of us.” There is a rumor that there may be a public hearing on tax cuts coming up in the next week, so watch for alerts.
- Budget Targets. The first step in getting a budget moving is to announce budget targets. Once leaders decide how much money they want to spend next year, they will divide it up between the 10 budget areas (Administration/Regulation, Agriculture/Natural Resources, Economic Development, Education, Health/Human Services, Judicial Branch, Justice Systems, Infrastructure, Standings, and Transportation). Each of those budget subcommittees will then take that number and decide how much each agency, service, or program will get. That process takes time, even if budget targets have been agreed to by both the House and Senate. Without joint budget targets, the House and Senate will come up with their own budget bills, and then have to negotiate. It adds to the overall time needed to pass a budget. This standstill on the budget (and tax cuts) has many people predicting session will go until mid-May. I’m not there yet.
Jerry Foxhoven was finally confirmed as Director of the Department of Human Services on March 21. The Senate voted to confirm him 38- 11; he needed 34 votes (2/3 of the Senate). Earlier this week, Governor Kim Reynolds fired the Director of the Iowa Finance Authority after finding “credible accusations of sexual harassment.” David Jamison, a former Story County Treasurer, ran the agency since 2011. The agency offers housing, community development, and infrastructure programs and runs the state’s title guarantee program. Carolann Jenson, who served as IFA’s chief program officer, will act as interim director.
The Senate still needs to confirm over 150 of the Governor’s board and commission nominees (but they can do most of them with a single “en bloc” vote).
Governor Takes Action on 56 Bills
Governor Reynolds has signed 56 bills into law, and plans to sign two more early next week. They include:
- Telehealth (HF 2305): All state-regulated health insurance plans will have to cover telehealth-delivered services if those services are covered if delivered in person. It applies to plans renewed or started after January 1, 2019 (so full implementation does not begin immediately).
- Concierge Medicine (HF 2305): Health care providers would be able to offer membership-based primary care services beginning July 1, allowing Iowans access to free primary care services and reduced cost lab testing. Similar legislation has been enacted in Nebraska.
- Expanded Newborn Safe Havens (SF 360): EMS providers, firefighters, and other first responders are added to the state’s Newborn Safe Haven Act, so beginning July 1 they will be able to accept newborns similar to institutional providers like hospitals.
- Suicide Prevention & Awareness (SF 2113): School employees will be required to receive one hour of suicide prevention and awareness training each year, beginning July 1, 2019. The training is to be evidence-based, include information about the identification of Adverse Childhood Experiences (ACES) and mitigation of toxic stress response.
- The Governor announced plans to sign another bill on Monday - SF 2349 (Farm Bureau Non-ACA Complaint Plan). The Iowa Farm Bureau will be allowed to offer its members a non-ACA compliant individual health insurance plans beginning July 1, 2018. The bill basically states that the Wellmark health insurance plans offered to individuals through the Iowa Farm Bureau are not “insurance” and therefore do not have to comply with ACA requirements. Supporters say this approach is similar to what has been approved in Tennessee (opponents say the federal government just rejected a similar plan in Idaho). Now that its signed, I guess we’ll see if it survives a challenge.
Governor Kim Reynolds also signed
House File 2456
on Thursday, the final step in turning the recommendations of the 23-member
Complex Needs Work Group
into law. Last year, Iowa lawmakers asked a group of Iowans representing providers, families, law enforcement, advocates, county MH/DS regions, and others to develop a set of recommendations to fill the gaps in services for persons with complex mental health and disability services needs. The goal was to get people with mental illness out of jails and emergency rooms, and into the services they need, with an emphasis on providing those services locally, and in smaller community-based settings.
"This legislation was pushed over the finish line by individuals and families who knew firsthand the importance of having a robust mental health system and the pain caused when services they or a loved one needed weren’t there,” Gov. Reynolds said. “I know we can do better, and with this legislation, we will do better!”
outlined six basic recommendations, and nearly all of them were included in the legislation. The bill requires the following services be made available throughout the state:
- Access Centers to provide short-term care for those in crisis, and provide resources needed to get Iowans back home to their families. The bill calls for at least six of these to be located around the state.
- Assertive community treatment (ACT) teams to provide individualized treatment and support to individuals with mental illness in their homes, 365 days a year. The bill calls for at least 22 ACT teams to be established.
- Intensive residential service homes will provide individuals with severe and persistent mental illness with the chance to live in smaller community-based settings close to home, while receiving the 24-hour intensive services needed to address their individual needs. The legislation calls for a total of 120 beds to be available statewide (to be scattered, with facilities preferably serving no more than four individuals at each site, with a maximum of 16 allowed).
- A single statewide 24-hour crisis hotline will replace the ones managed by each individual MH/DS region, but it will continue to connect people to the local resources they need.
- All of the existing crisis services provided by MH/DS regions are moved to the list of "core services" - so mobile response, 23-hour crisis observation and holding, crisis residential services, subacute and crisis stabilization community-based services are no longer considered "extra services." They are now required core services to be available throughout the state. The existing subacute bed cap is removed, so regions are free to develop these beds based on the needs of their community.
House File 2456
also makes changes to free up hospital beds quicker and allows hospitalization hearings to be held via video conference, and improves communications between mental health professionals and law enforcement (consistent with ethics, and still permissive not mandatory).
While this is an impressive list of recommendations, all present at the bill signing acknowledged there is more work to be done. "Creating a mental health system that we envision is complex and it can’t happen overnight. I look forward to building on the momentum that we have here today,” Reynolds emphasized. “There is more to come.”
Mary Neubauer, whose son took his own life last year, used her skills as a lobbyist (for the Iowa Lottery) and former journalist (for AP) to tell her story and ask lawmakers for action. She was at the bill signing. “Today is a significant day. This is an acknowledgment of the difficulties that have existed here in Iowa, of the people who haven’t gotten the help that they’ve needed,” said Neubauer. “This puts in place a framework for the real work to begin to develop the programs and to put in place the capacity and the help that is needed...The follow through is absolutely critical. This is an important starting point that, frankly, we have never reached before in Iowa, but truly now the real work begins.”
So what are those next steps?
- Make sure funding is available for these services. MH/DS regions and Medicaid MCOs are required to pay for these services, yet funding for both is strapped. While many regions have some funds available now, they will run out of their "reserves" eventually and will need a stable source of funding. At least two regions (Polk County & Eastern Iowa) have capacity to do these services, but do not have the resources to pay for them now. Because these services will be available only as funding allows, fixing the funding is an important next step. House File 2456 calls for an interim committee this summer to review funding for these and other services delivered through the MH/DS regions, and determine funding needed to make sure they are available statewide. Action will be needed on this when the Legislature returns in 2019.
- Begin work to fill gaps in the children's mental health system. House File 2456 focuses entirely on the adult system, but the work group acknowledged work needed to be done to implement the recommendations of the Children's Mental Health and Well-Being Work Group. In response to this, the Governor announced that she will be signing an Executive Order to begin this process, and start to implement the recommendations made by this group, in preparation for more action in 2019. We will send out more information on this when the Executive Order is available.
- Address the role of tertiary care hospitals in the system. House File 2456 directs DHS to pull together stakeholders to review the role of tertiary care psychiatric hospitals in the array of mental health services and make further recommendations if necessary. The workgroup will include the Department of Inspections and Appeals, representative members of the Iowa Hospital Association, managed care organizations, the National Alliance on Mental Illness, the mental health institutes, and other interested stakeholders. A report is to be completed by November 30, 2018 (so expect work to begin soon).
- Further streamline commitment processes. House File 2456 also directed DHS to bring stakeholders together to review the mental health and substance use disorder commitment processes and make recommendations for improvements in the process. The workgroup will include the Department of Public Health, representative members of the judicial branch, the Iowa Hospital Association, the Iowa Medical Society, the National Alliance on Mental Illness, the Iowa State Sheriffs’ and Deputies’ Association, Iowa Behavioral Health Association, and other interested stakeholders. This report is due on December 31, 2018 (so work here will also begin soon).
- Last (but definitely not least) - rules! Legislators pass bills. Bills are signed into law by the Governor. But state agencies need to figure out how to implement those laws, and they do that by writing rules. Administrative rules are important here, because they will more fully define these services, set service provider standards, establish reimbursement rates (always key to making services available), access standards, implementation dates, and possibly even location of the services. While DHS has been asked to get rules in place quickly, it will still need to go through the normal rules process that includes many opportunities for input, including public hearings, public comment period, required responses to comments, and a review by a legislative panel (called the Administrative Rules Review Committee). As the saying goes, the Devil is in the details (and this is where the details are outlined).
Finally, the House unanimously passed the
Medicaid MCO Directives Bill
), which directs MCOs to follow certain industry best practices, including requirements that MCOs pay timely claims, denied claims include reasons for denial, the development of standardized provider enrollment forms and credentialing processes, extension of services for members who win appeals, requirement that court-ordered substance use or mental health treatment be authorized for at least five days, required DHS review of any level of care reassessments that decrease services, mandate that MCOs continue services at existing levels for those whose level of care determinations find no change, and an independent audit of all small claims for long-term care supports and services.
In addition, the bill establishes a health home work group (with representation of health home providers and MCOs) to review the health home program. Another work group (with MCOs and Medicaid providers) will determine the effectiveness of prior authorizations used by MCO and develop a threshold when they are no longer needed.
The bill is now in the Senate Appropriations Committee, assigned to Sen. Mark Costello (R-Imogene). During a committee meeting several weeks ago, Sen. Costello said this bill will not move, but that MCO-related changes would be done in the Health/Human Services Budget (which he co-chairs and starts in the Senate this year). So while this bill might not move, the issue itself is still very much alive.
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