MHA Update Michigan Organization of Nurse Executives Annual Advocacy Day March 5, 2014

1. MHA UpdateMichigan Organization of Nurse Executives Annual Advocacy DayMarch 5, 2014 Chris Mitchell Senior Director, Advocacy

2. Political setting – March 2014 • Term limits for state elected officials, lawmakers lack experience • 2014 - Election of leaders who will guide the state and country for next 2 - 8 years • State budget - surplus revenue, yet potential Medicaid provider rate cuts • Federal issues - Sequestration, physician payments, regulatory costs • National health reform implementation underway – year 4 • Medicare and Medicaid account for at least half of avg. hospital revenue • Over 1.3 million people uninsured in Michigan • Over 1.8 million people in Medicaid, 167,000 eligible but not enrolled and 322,000 people projected to be added in 2014

3. Election 2014 – Important Dates • Primary Election: August 5, 2014 • Election Day: November 4, 2014

4. Election 2014 - State • Governor • Incumbent Gov. Rick Snyder (R) v. Mark Schauer (D) • Attorney General • Incumbent Bill Schuette (R) v. Mark Totten (D) • Secretary of State • Incumbent Ruth Johnson (R) v. Democratic challenger (to be determined) • State Supreme Court (2 incumbents, 1 open seat) • State Senate (10 open seats) • State House of Representatives (38 open seats)

5. Election 2014 – Federal • U.S. Senate • U.S. Rep. Gary Peters (D) v. Terri Lynn Land (R) • U.S. House of Representatives • All 14 Michigan seats will be elected (2 open seats)

6. 2014 State of the State • “The Victory Lap” • 35 minutes reflecting on his accomplishments • Politically safe issues • Protecting seniors, increasing EC education funding, attracting more immigrants to Michigan • Resolution endorsing a Federal Balanced Budget Amendment • Health care issues not prevalent in address • Noted successful passage of Health Michigan plan • Health Endowment Fund - BCBSM Mutualization • Mental Health and Wellness Report • No mention of auto no-fault reform

7. FY 2015 State Budget – MHA Priorities • Maintain Medicaid rates paid to providers • Restore GME funding to 2010 payment level • Budgets have carried forward $5m in cuts to GME • Maintain $40m provided for rural and sole community hospital pool • Maintain access for Medicaid beneficiaries in rural areas • Reauthorize $2b of federal funding to support Health Michigan plan • Medicaid Expansion • Maintain funding for another year of Primary Care/OB rate increases ($100m GF) • Federal funding expires after first quarter of FY 2015

8. FY 2015 Executive Budget Recommendation • Fairly straight forward, state budget stabilized, facing a surplus • $ 350m for Detroit pensions • One-time tax rollback for citizens • Increased funding for early childhood education • Funding for Mental Health and Wellness report recommendations • $36m Small & Rural funding eliminated (one-time) • $4.3m GME funding eliminated (one-time) • Reauthorization of $2b of federal funding to support Healthy Michigan Plan (Medicaid Expansion) • Partial Continuation of Medicaid primary care rate increases (50% rate bump)

9. Unfinished Business – Resolve HICA Tax Shortfall • Sunset extends four years • $115 million Medicaid budget hole • Administration backed away from resolution by Oct. 1 • Senate Solution: $114.5m GF (RRR/surplus) in SB 608 passed 32-6. Headed to conference committee • Many options on the table • GF savings resulting from Medicaid expansion $125 m • $1b budget surplus • $25 Medicaid tax on auto premiums in auto no-fault reform bill • Legislative support for executive order reductions difficult to achieve given state revenue surplus - Medicaid provider reimbursement reductions remain a threat

10. State Advocacy • Proactive • Swing-bed modifications (SB 446) • CRNA Opt-out (SB 180) • Standard of Care Protection Act (Provider Shield – GA) • On Watch • Nursing Scope of Practice (SB 2/SB 568) • CON Reform/Repeal • Defense • Auto no-fault reform • Nurse staffing ratios

11. Auto No-fault - Reform and Preserve • MHA Board priority, protect auto no-fault law • House Bill 4612 reported from House Insurance Committee as expected – MHA opposed • House and Senate Democratic caucuses united in opposition to HB 4612 • 25 House Republicans opposing HB 4612 • 8-11 Senate Republicans opposing HB 4612 • Speaker of the House, Governor looking for path to resolve stalemate

12. Auto No-fault – Speaker’s Latest Proposal • $10m hard benefit limit (cap) • Mandated fee schedule at 125% workers’ comp • 30-day Prompt payment required • Caps on attendant care and physical therapy • Creation of a state-run MCCA, would handle catastrophic claims • $25 Medicaid tax per vehicle to resolve HICA shortfall • Creation of a low-income auto policy (133% fpl) • Two-year 10% reduction in auto insurance rates

13. Scope of Practice for Advanced Practice Nurses • SB 2- Sen. Mark Jansen (R-Gaines Twp) • Would define and create specific licenses for Certified Nurse Practitioner (CNP), Certified Nurse-Midwife (CNM) & Certified Clinical Nurse Specialist (CCNS) in Public Health Code • Provide physical examinations and screening • Prescriptive authority after apprenticeship • Diagnosis, treatment and management of acute and chronic diseases • Ordering, performing and interpreting lab and imaging studies • Nov. 13: Passed the Senate 20-18; referred to House Health Policy Committee • Next steps??

14. Certified Registered Nurse Anesthetists (CRNA) Issue • Limited access to anesthesiologists in rural areas has lead to multiple member requests that MHA advocate for special CMS opt-out provision from federal supervision requirements for CRNAs Problem • Shortage/availability of anesthesiologists • Surgeons unwilling to provide supervision of CRNAs • Cost of anesthesiologist vs. volume of care need in rural areas Option • Governor attestation to CMS that in consultation with Boards of Medicine and Nursing, the best interest of the citizens is to opt-out of physician supervision requirement, consistent with state law • Flexibility allowed for individual facilities to continue to require physician supervision of CRNA’s • 17 states have opted-out of supervision requirement

15. Certified Registered Nurse Anesthetists (CRNA) • MSMS President for 2014 is an anesthesiologist; strongly opposed to potential changes • Long, multi-year process in virtually all states, no indication that Michigan will be different • Governor’s letter alone not sufficient in Michigan • Attorney General opinion #6567 (1989), anesthesia may be delegated, but only under the supervision of a physician • MHA and Michigan Association of Nurse Anesthetists pursue legislative fix • Passage of SB 180 necessary; Michigan Public Health Code regarding CRNA scope of practice must change • Sponsored by Sen. Mike Green (R-Mayville), adds administration of anesthesia by a CRNA to practice of nursing definition • Rep. Foster will introduce a House version this year

16. Nurse Staffing Ratios • HB 4311/SB 225 – Rep. Jon Switalski (D-Warren/Sen. Rebekah Warren (D-Ann Arbor) • Would require hospitals to create an acuity system and annual staffing plan including minimum nurse-to-patient ratios and provide for penalties • Number one issue for the MNA • Key issue for their annual advocacy day • After massive defeats in last session, back with a vengeance • Action not likely this session due to political environment