February 23, 2007

This week again focused on hearing as many of the introduced bills in committee as possible. Over 1400 bills have been introduced as usual. Approximately 2000 bills will ultimately be filed. The Governor’s MoHELA plan and the cable/ ATT legislation dominated floor time.

News this week includes:

CAFO's

Below is a recent Columbia Missourian article on CAFO's.

Ag Bill Pits Local vs. State Control

Factory farms would get greater protection against suits alleging nuisances.

JEFFERSON CITY — For at least two years, the lagoon on Charles Sears' Pettis County hog farm leaked, spilling 5,000 to 10,000 gallons of waste into a nearby stream each week.

And for two years, Sears said he asked the Missouri Natural Resources Department to help solve the problem. But department representatives never inspected the site, he said. They even skipped their mandatory annual inspection of the farm.

"The state is not doing their job," said Sears, adding that the only state cooperation he has received was from the Attorney General's Office.

Sears, a former contract farmer, no longer raises hogs. But his confidence in the state's ability to regulate agricultural operations remains low.

Sears said the state does not have the personnel to properly supervise Missouri's concentrated animal feeding operations — large farms with thousands of animals. State officials continually failed to inspect his farm, he said. Some even told him to keep quiet about his lagoon leak.

"There's a lot of things that should be changed," Sears said.

Nullifying existing health ordinances and taking control from local governments is not a change Sears views as beneficial.

But that's what the state is considering.

A bill sponsored by a western Missouri senator could nullify local ordinances governing agricultural operations, giving the state nearly sole authority in regulating farming-related activities.

The bill, sponsored by Sen. Chris Koster, R-Harrisonville, would prohibit local governments from adopting or upholding agricultural health regulations that are stricter than the state's standards. The act would expunge local laws for licensing and operating farms that are not identical to state regulations.

The bill, supported by Gov. Matt Blunt, also gives farms greater protection against lawsuits that accuse large-scale farms of creating nuisances.

Two years ago, former Sen. John Cauthorn, R-Mexico, proposed a similar bill, which passed in the Senate but was defeated in the House. The issue has since divided Missouri's agricultural industry, often pitting environmentalists, smaller farmers and local officials against large-scale farmers and state officials.

"We've been dealing with this for a very long, long time," said Dick Burke, executive director of the Missouri Association of Counties, which opposes the bill. "Folks feel very strongly on both sides."

So far, 16 Missouri counties have their own agricultural health ordinances, which control everything from livestock odor to setbacks between farms and homes. Most of these ordinances oversee health affects related to CAFOs.

"I was glad to have the laws to protect everybody," Sears said. "As long as I abide by the law, I was OK."

Among other stipulations, Pettis County's health ordinance, adopted in 1997, regulates where a farmer can spread animal waste and where farmers could build CAFOs in relation to existing homes and communities.

Sears, however, said Pettis County commissioners, like state officials, could be stricter in their enforcement of the regulations.

Koster said he sponsored the bill to help Missouri establish a unified regulator structure that would govern agricultural operations in an environmentally friendly manner. Koster argued that allowing regulations to vary from county to county could drive ranchers and farmers out of the state to locations where laws are unified and more lenient. Koster said many in the agricultural industry are already moving their businesses to South America.

"If we regulate agriculture at such a high level, Missouri's industries are already picking up and moving," Koster said.

Koster said the bill was a "major priority" for the legislature this session. Sen. Dan Clemens, R-Marshfield, is the chairman of the Senate's Agriculture, Conservation, Parks and Natural Resources Committee. He said the state's animal agriculture business would disappear if counties continue to push their own health ordinances.

"A lot of focus, especially in north Missouri, has been to almost eliminate animal agriculture," Clemens said.

Agriculture is the state's number one industry, with animal agriculture making up 53 percent of the industry, Clemens said.

But Clemens said he was not in favor of a bill that would give the state complete control of the issue. He said county officials should have some input into regulating agricultural operations. Local officials could possibly serve as members of a mediation or advisory committee that would make recommendations to the state.

"We're looking to get a good compromise bill," Clemens said. "We're getting there." One of the groups legislators are negotiating with is the Missouri Association of Counties.

Burke, from the association, called the bill — as it is currently written — a "bad piece of legislation" since it would strip local governments of their power.

"If you take all this away, what's going to regulate these guys from being so dishonest?" Sears said.

The association's Agricultural Impact Task Force recommended the state codify into state law a model county ordinance governing CAFOs. The task force also recommended that local and state groups continue to address odor and water-quality concerns CAFOs produce, and that county health departments still be allowed to help combat disease and environmental hazards surrounding animal operations.

Burke said he hoped the association and legislators would agree on a compromise. Tim Gibbons, communications director for the Missouri Rural Crisis Center, which represents 5,500 member-families, said the center opposed any bill that would usurp local control. He said county governments needed individual ordinances because the state's minimum standards are too low.

"These aren't a bunch of people who want to make health ordinances," Gibbons said. "They're not radical commissioners."

"The county health ordinances would not be there if the state was doing its job," said Bob Svoboda, whose home and farm border a CAFO in Daviess County. Svoboda also opposes the bill.

Gibbons said county health ordinances aren't meant to chase away CAFOs and other agricultural operations. Rather, the local ordinances are simply rules for such operations to abide by.

Gibbons also criticized the bills supporters for pandering to big business, which the health ordinances tend to regulate most. He said Koster's bill does not help support the average Missouri farmer.

"It's politicians being influenced by industry groups and money," Gibbons said. Koster said he's simply acting as a moderator to the bill and has no personal agenda. But Cargill and Premium Standard Farms, two of Missouri's largest hog producers, donated $26,500 to the state's Republican Party or to its candidates in 2006. Neither company contributed to Koster or the Democratic Party or its state candidates.

Leslie Holloway, director of State and Local Government Affairs for the Missouri Farm Bureau, an organization that supports the act, said the strict county health ordinances aren't needed. Both the state and federal government already regulate agricultural operations. Plus, Holloway said local regulations are often based on conflicting science. She also said farmers and ranchers need increased protection from nuisance lawsuits. Koster's bill provides such protection. Under the bill, a farm would be allowed to "reasonably diversify or modernize under similar criteria" and remain protected from nuisance lawsuits and ordinance violations. The act also protects farms from nuisance lawsuits concerning clearing land, managing livestock, and applying pesticides and herbicides.

Holloway said officials adopted most laws protecting agricultural operations from lawsuits in the 1980s. The industry has since changed, she said, adding she has seen an increase in lawsuits against farms.

"We're afraid that protection isn't strong enough," Holloway said.

Bill Would Expand Advanced Practice Nurses' Prescriptive Authority

Missouri Hospital Association, Missouri Nurses Association and others supported a bill that would authorize advance practice nurses to prescribe controlled substances under the auspices of a collaborative practice arrangement with a physician. Senate Bill 511 was opposed by several physician organizations and individual physicians, who argued that advanced practice nurses lack the expertise necessary to prescribe highly addictive and dangerous drugs.

Missouri is one of only a few states that prohibit advanced practice nurses from prescribing at least some controlled substances. In its testimony, MHA noted that the restriction makes it difficult for hospitals to recruit advanced practice nurses to this state.

In reviewing the bill, members of the Senate Financial, Governmental Organizations and Elections Committee encouraged proponents and opponents to develop compromises to address concerns raised by the bill.

Committee Supports Bills on Data Confidentiality and Abuse Protections

This week, the Senate Health and Mental Health Committee voted to advance Senate Bill 2. The measure would create state laws designed to protect the confidentiality of "personal health information," with criminal penalties for knowingly obtaining, receiving or selling such information without consent. It specifically authorizes health care providers to continue to use and disclose health information as permitted or required by federal or state law.

The committee also approved Senate Bill 3, which concerns the investigation and prosecution of abuse and neglect of mentally ill or developmentally disabled people. The impetus of the bill is a series of recommendations from a task force appointed to review procedures in the Department of Mental Health in the aftermath of allegations of abuse. The bill would expand access to final reports of abuse and neglect investigations, create a team to investigate deaths of clients of the Department of Mental Health and provide for the development of standards for use by physicians and hospitals to identify suspicious deaths of mental health clients. It revises standards for reporting suspected abuse and increases potential fines for community providers failing to address problems identified in Department of Mental Health licensing inspections.

Senator Introduces Medicaid Reform Proposal

Late this week, Senate Majority Leader Charlie Shields (R-St. Joseph) introduced a bill to implement many of the Medicaid reform proposals advanced by Governor Matt Blunt and the Senate Republican caucus. The bill is Senate Bill 577.

• The bill would rename Medicaid as "MO HealthNet" and create a MO HealthNet Division in the Department of Social Services to replace the current Division of Medical Services.


• MO Health Net will act as a third-party administrator to offer enrollees a choice of coverage in one of three delivery models: (1) a capitated risk-bearing system "operated generally under a traditional managed care model"; (2) an administrative services organization model that does not involve capitation and has the state retain provider reimbursement, pharmacy management, network management and eligibility determination functions; and (3) a state point-of-service care management program.
• Three-year contracts to implement the risk-bearing and administrative services organization models will be awarded based on competitive bids.
• Health plans will offer enrollees "health care advocates" to coordinate care and provide health risk assessments. They also will report quality and satisfaction indicators. The state will establish copayment requirements for services and set higher coinsurance requirements for nonemergency use of hospital emergency departments.
• Vendors of all of the coverage programs will provide enrollees with electronic membership cards that allow them to pay cost-sharing obligations. The cards also will provide a vehicle for accumulating health improvement points. Those points will be based on "healthy practices, responsible lifestyle choices and signing a health improvement participant agreement" and may be used to receive approved health care expenditures consistent with the enrollee's plan of care. The bill specifically mentions that enrollees whose plan of care involves physical, occupational or speech therapies may receive those services if they discuss their recommended plan of care with their health care advocate and the General Assembly and Governor approve funding for the services.
• Vendors offering services within 30 miles of a FQHC, rural health clinic or community mental health center must establish partnerships with them.
• By July 1, 2013, all MO HealthNet enrollees will participate in one of the three delivery models. Parents and children not already enrolled in Medicaid managed care will be enrolled in one of the three models by July 1, 2009. One-half of the aged, blind and disabled will be enrolled in one of the delivery models by July 1, 2010, with the rest enrolled by July 1, 2013.
• MO HealthNet providers in a risk-bearing managed care model or an administrative services organization model must participate in a pay-for-performance payment incentive program. Providers in the state's point-of-service care management model may participate in the pay-for-performance system.
• The bill authorizes a premium offset program to allow MO HealthNet funds to pay part of the cost of coverage if the employer and employee pay their shares of the required premium.
• Current state laws governing a Missouri Long-term Care Partnership are reworked to allow those applying for MO HealthNet coverage of nursing home care to exempt assets equal to the value of benefits paid under a private long-term care insurance policy.
• Nursing home coverage under MO HealthNet will not be available to those with more than $500,000 equity in their home.
• Foster care children who turn 18 years old and become ineligible for coverage may qualify for coverage through age 21.
• An oversight committee of legislators, state officials, consumer representatives, "advocates of health care", and providers is created.
• A separate state account is created to fund initiatives relating to electronic medical record systems, telemedicine and related uses of health technology.
• The July 1, 2008 expiration date on state laws governing the Medicaid program is repealed.

Emergency Responder Liability Bill is Reviewed and Approved

The House Crime Prevention and Public Safety Committee approved legislation designed to enhance the availability of health care workers to respond to major emergencies and natural disasters. House Bill 579 would grant immunity from medical liability if the health care practitioner volunteers to be deployed by the governor or a state agency to respond to an emergency declared by the governor. It would apply to practitioners from Missouri and other states and would not apply to damages caused by willful or wanton acts or omissions.

A similar bill, Senate Bill 380, was presented to a Senate committee this week.

House Committee Passes Supplemental Appropriations

The House Budget Committee this week passed House Bill 16, sponsored by Representative Allen Icet, R-Wildwood, which provides supplemental appropriations that will be spent in the current state fiscal year. Included in House Bill 16 are $60 million for FQHC capital expansion projects and $3.4 million for Primary Care Resource Initiative Program (PRIMO) and Area Health Education Centers (AHEC). Both are funded by General Revenue funds. The bill now awaits action by the full House of Reprsentatives.

MO Health Net

Below is a recent new article on the Governor's Health Plan.

Daily Health Policy Report

Missouri Gov. Matt Blunt (R) on Thursday announced a bill (HB 818) that seeks to reduce the number of uninsured state residents, the Kansas City Star reports. The legislation -- developed by Blunt, state Rep. Doug Ervin (D) and state Senate leaders -- in large part would affect workers at companies with fewer than 50 employees. The bill would establish a state agency to administer a program through which insurers could offer health plans. Employees of companies that decide to participate in the program could contact the agency for information on the available health plans. Companies that participate would determine a flat per-employee amount to contribute toward the cost of health insurance premiums for employees, and workers would cover the remainder of the cost. The program would make contributions eligible for inclusion in tax-free flexible spending accounts, which workers could use to cover part of the cost of the health insurance premiums. Blunt has proposed to spend $20 million to establish the program. In addition, Blunt and Ervin raised the possibility that the state could subsidize the cost of health insurance premiums for low-wage employees.

Potential Effects

According to Ervin, the program would allow employees to retain health insurance in the event that they switch jobs, make workers more aware of the cost of health care and help individuals with chronic illnesses afford coverage. He said, "By moving away from an employer-based health care model, we're taking a pretty radical step," adding, "But eventually it also will help with the overutilization problem. No one spends their own money the way they spend other people's." Missouri officials did not estimate the number of state residents who would participate in the program, but Ervin said one study projected that the program could reduce the number of uninsured residents by as much as 20%.

Civil Immunity

On Monday SB 380 was heard. This legislation sponsored by Senator Koster currently states that any health care professional licensed, registered, or certified in this state may be deployed to provide care in the event of a declared emergency, subject to approval by the state emergency management agency. This act provides that any health care professional licensed, registered, or certified in any state who volunteers may be deployed to provide emergency care. This act also provides that health care professionals deployed by the governor shall be immune from civil liability in the delivery of health care necessitated by the emergency, except for willful or wanton acts or omissions.

This act is similar to SCS/SB 889 (2006) and SCS/HB 1118 (2006).

I entered testimony in support from MOALPHA. Emergency response Personnel Association, the Missouri Hospital Association and ambulance districts testified in favor.

The Missouri Association of Trial Attorneys will oppose the measure.

House Bill 788

Next week on February 27th, Representative Wayne Cooper, MD will have his HB 788 heard in committee.

HB 788 changes the laws regarding public health emergency preparedness. The bill:

1. Defines "emergency plan," "responder," and "volunteer";
2. Specifies that health care professionals and emergency responders deployed during an emergency are exempt from civil penalty unless the act or omission is intentional or careless;
3. Specifies that the Governor, in a state of emergency, can issue an executive order requiring medical care be given at temporary facilities if the number of seriously ill or injured persons exceeds hospital capacity;
4. Allows the Governor to waive or suspend administrative rules that would hinder or delay the ability of the Department of Health and Senior Services to respond to a declared emergency;
5. Specifies that the department can recruit, train, and accept the services of citizen volunteers to dispense medication; and
6. Requires the department to provide volunteers with access to professional staff for training and oversight, develop written rules, and make sure volunteers understand their responsibilities.

In consultation with DOH I have visited with Ross and Mahree to have a MOALPHA representative testify.

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