In 2019, the American College of Surgeons (ACS) State Affairs team in the Division of Advocacy and Health Policy led a proactive state advocacy program that resulted in the introduction and passage of Stop the Bleed® legislation and legislation addressing surprise billing for out-of-network services, both of which were discussed in recent issues of the Bulletin. In addition, state lawmakers have been receptive to adopting legislation that is aligned with the College’s policies in the areas of cancer coverage, trauma prevention, and access to bariatric surgery as a result of the ACS Chapter Lobby Day grant program and state member grassroots advocacy.
Using state legislative tracking services, the ACS monitored more than 1,800 bills across all 50 states during state legislative sessions between January and June. State Affairs initiated 21 calls to action for Fellows and other ACS members to communicate with their state legislators, resulting in more than 13,000 e-mails that were sent to 406 state representatives and senators. Working with ACS state chapters, Action Alerts were sent to support passage of the following state-level bills:
- Connecticut’s universal helmet law (H.B. 7140) legislation mandating that all health insurers in the state offer coverage for coverage of bariatric and metabolic surgery (S.B. 317), and a law that protects funding for trauma care
- Indiana, Tennessee, and Texas legislation (H.B. 1063, H.B. 215 and S.B. 259, and H.B. 496, respectively) that calls for providing Stop the Bleed training and bleeding control kits in public schools
- Louisiana legislation (H.B. 380) that increases trauma funding in the state
- Louisiana (S.B. 76) and New York (A. 6163 and S. 4346) bills implementing automobile passenger safety standards
- Conversely, Action Alerts were sent calling for chapters and ACS members to oppose the following:
- Legislation on Maintenance of Certification (MOC) in Indiana (S.B. 203) and Michigan (H.B. 4135)
- Surprise billing legislation in Georgia (H.B. 84 and S.B. 56)
- Repeal of the universal motorcycle helmet laws in North Carolina (H.B. 276) and Missouri (S.B. 147)
- Legislation in Pennsylvania to grant independent practice for certified registered nurse practitioners (S.B. 25)
- A provider tax on ambulatory surgery centers outlined in Pennsylvania Gov. Tom Wolf’s (D) budget proposal
Surgeons also engaged in face-to-face meetings with their state lawmakers during chapter lobby days. In 2019, ACS chapters in 27 states received grants as part of the ACS Chapter Lobby Day Grant Program. For a complete summary of ACS Chapter Lobby Day activities, read the Bulletin article “2019 State Lobby Days: Advocating for patient care in state capitols” in the October issue.* As noted in this Bulletin article, ACS Chapter Lobby Days are important, if not vital, components of efforts to pass or defeat legislation at the state level. One chapter in particular, the Georgia Society of the ACS, remains a lobbying rock star when it comes to supporting chapter leadership for advocacy, a comprehensive legislative strategy to effectively implement a grassroots advocacy agenda and employs a long-term lobbyist who provides guidance and expertise in legislative advocacy.
The Georgia Society was inadvertently left out of the Bulletin article wrapping up lobby day activity in 2019, but it should be noted that the Society’s February 13 lobby day exceeded expectations for attendance, with more than 100 surgeons and others engaged with state legislators. During the lobby day, attendees “worked the rope line,” where constituents were able to request that their legislator leave the Senate or House chamber and come out into the hallway to talk about a specific bill or issue. During this lobby day, surgeons were able to discuss continued budget support for the Georgia Trauma Commission and the reinstatement of bariatric surgery coverage for the state health benefits plan.
In addition, society members thanked legislators for their support last year of the hands-free Georgia legislation that bans the use of any cellular device while driving and reminded lawmakers that their passage of the distracted driving legislation had a direct impact on reducing the number of lives lost on Georgia highways. To top it off, information and training tables were set up in the capitol to provide additional opportunities to discuss issues with legislators and their staff, as well as to provide Stop the Bleed training and remind legislators of the importance of their continued support for bleeding control kits in public schools—legislation that was passed in the state several years ago.
In addition to grassroots advocacy, the ACS directly sent letters or coordinated with state chapters 15 letter-writing campaigns stating the College’s policy positions and official Statements approved by the ACS Board of Regents. These letters also supported ACS Fellows testifying before state legislative committees regarding Stop the Bleed legislation in Tennessee and Texas and opposing independent practice for advanced practice registered nurses in Indiana.
Advancing a proactive legislative agenda
The College continuously monitors and supports a range of health care and safety issues in the states, but two ACS priorities dominated the 2019 state advocacy agenda: bringing Stop the Bleed training and bleeding control kits to public places and expanding insurance coverage for bariatric surgery.
Stop the Bleed legislation was introduced in California (A.B. 1705) and Massachusetts (H. 870 and S. 1337). Legislation to require installation of bleeding control kits and Stop the Bleed training of school personnel was introduced in Illinois (H.B. 3432), Michigan (H.B. 4334), Missouri (H.B. 1005 and H.B. 249), New York (A. 4484), North Carolina (H.B. 288), Pennsylvania (H.B. 1072), and Tennessee (S.B. 259 and H.B. 215).
ACS-sponsored Stop the Bleed legislation was enacted in Indiana (H.B. 1063) and Texas (H.B. 496), and Arkansas passed legislation (H.B. 1014) that makes participation in Stop the Bleed training a requirement for high school graduation. Both the Indiana and Texas Chapters led advocacy campaigns to push enactment of their respective bills, including using their lobby days to educate lawmakers on the importance of the legislation to garner support and initiating grassroots as mentioned above, as well as working with other organizations to achieve legislative success. For a detailed description of the advocacy effort in Texas, read the Bulletin article, “Stopping the bleed in Texas: The importance of surgeons and health care professionals as advocates,” in the November issue.†
The Kansas and Connecticut Chapters led efforts to enact legislation in their states to expand essential health insurance benefits to include coverage for bariatric surgery. The Connecticut Chapter used an advocacy strategy that included submitting testimony to legislative committees, and initiating grassroots Action Alerts and lobby day meetings with key legislators in support of their bariatric coverage legislation (S.B. 317). The Kansas Chapter met with House Majority Leader Dan Hawkins (R) and Insurance Commissioner Vicki Schmidt to discuss the potential need for state legislation to expand coverage and attempted to negotiate with the state’s leading insurance providers; however, other pressing issues in Kansas distracted attention from the effort.
The Louisiana Chapter added its support for legislation (S.R. 35) calling for the state to study the effects of expanding bariatric coverage at a meeting with the sponsor, Sen. Gerald Boudreaux (D), and other legislators during the chapter’s lobby day event. The chapter plans to continue to focus its advocacy efforts in 2020 on expanding access to bariatric surgery.
Billing for out-of-network services
In 2019, out-of-network surprise medical bills became a pervasive public policy topic in the states, as well as the U.S. Congress, with 28 states introducing various proposals to address the issue: California, Colorado, Connecticut, Georgia, Hawaii, Kentucky, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Washington, and West Virginia.
The College has been engaged in billing for out-of-network services at the state level over the past several years and was able to use that experience to influence some of the legislation that passed in Colorado, Nevada, Texas, and Washington. The College worked with the Texas Medical Association to secure the inclusion of amendments in legislation (S.B. 1264) to protect surgeons and ensure that the law did not impede patients’ ability to choose their preferred physician for surgery. The Georgia Society of the ACS employed grassroots Action Alerts and direct lobbying to defeat insurance industry-supported legislation (H.B. 84 and S.B. 56). A detailed summary of those bills that were enacted can be found in the Bulletin article, “State legislatures consider surprise billing legislation in 2019,” in the November issue.‡
MOC
Preventing government intrusion on physician MOC requirements continued to be a priority for the ACS in 2019. MOC refers to the process that surgical and medical specialty boards use to verify that the physicians with whom they have engaged in lifelong learning through Continuing Medical Education activities, self-assessment, and quality improvement and have adhered to professional standards of practice. The ACS maintains the position that board certification and continuous certification are necessary to affirm that surgeons have the education, training, and competencies needed to provide quality care. This verification process is integral to ensuring that health care professionals have the rare privilege of self-regulation. Legislation restricting the use of MOC was introduced in Arkansas, Connecticut, Indiana, Massachusetts, Minnesota, North Dakota, New Jersey, New York, Rhode Island, Texas, Utah, and Virginia.
The College initiated grassroots Action Alerts and sent policy letters to lawmakers opposing the bills. Members of the Indiana and Virginia Chapters testified or officially recorded their opposition to the legislation (Indiana S.B. 203 and Virginia H.B. 1967) during committee hearings. In Texas, Fellows spoke with legislators about the College’s opposition to legislation (S.B. 1882) that would further government involvement in MOC during their lobby day in Austin on April 11. Those efforts resulted in successfully preventing the passage of the bills. However, legislation did pass in Arkansas (S.B. 339) and North Dakota (H.B. 1433) that restricts the use of MOC as a requirement for hospital employment and admitting privileges, as well as reimbursement.
Scope of practice
Legislation that would expand the scope of practice for nonphysician health care providers to include the practice of medicine and perform surgical procedures continues to be a significant focus of the College’s State Affairs team. The College and ACS chapters weighed in via letters, Action Alerts, and testimonies opposing state legislation that would allow optometrists to perform surgical procedures, and advanced practice registered nurses (APRNs) and certified nurse anesthetists to practice independently—all without additional training or educational requirements.
The ACS took action to oppose legislation that would permit optometrists to perform certain procedures, including laser surgery in Arkansas (H.B. 1251), Maryland (S.B. 447), and Nebraska (L.B. 528), and sent an Action Alert on the bill in Maryland. The bills in Maryland and Nebraska failed, whereas the Arkansas legislation was enacted despite an ACS Action Alert targeting Gov. Asa Hutchinson (R), which urged him to veto the bill.
In addition, the College opposed attempts by advanced practice nurse practitioners and certified nurse anesthetists to gain independent practice, sending letters of opposition in Alabama (S.B. 156), Arkansas (S.B. 184), Illinois (H.B. 2813), and Pennsylvania (S.B. 25). The College initiated an Action Alert to oppose the Indiana Senate bill that would allow APRNs to practice independently in the state (S.B. 394), and the Indiana Chapter testified in opposition to the House companion legislation (H.B. 1097). Both bills failed to advance.
In August, the ACS joined in grassroots advocacy efforts with other national specialty societies and sent a letter to Mississippi Gov. Phil Bryant (R) urging him to not “opt out” from the physician supervision requirement of nurse anesthetists. The governor had been seeking input from the Mississippi boards of nursing and medicine, as well as from the medical profession. As a result of these collaborative advocacy efforts, Governor Bryant decided to maintain existing policies in Mississippi.
Get engaged
ACS Fellow engagement is critical to ensure that surgeons continue to be leaders in patient safety and health care quality. Fellows are encouraged to support ACS advocacy efforts by participating in state chapter meetings and lobby days, building relationships with elected state officials (critical to effective grassroots advocacy), speaking about public policy issues with colleagues, responding to grassroots Action Alerts from the College, and attending the annual ACS Leadership & Advocacy Summit.
The ACS State Affairs team is always available to answer questions and provide background information regarding state issues and policy programs. Numerous state advocacy resources are available on the College’s website, and Fellows may contact staff at state_affairs@facs.org or at 202-337-2701.
*Johnson C. 2019 State Lobby Days: Advocating for patient care in state capitols. Bull Am Coll Surg. 2019;104(10):39-43. Available at: bulletin.facs.org/2019/10/2019-state-lobby-days-advocating-for-patient-care-in-state-capitols/. Accessed October 8, 2019.
†Walker JP, Martinez RD, Carpenter RO, Scherer E, Ghawi J, Stewart RM. Stopping the bleed in Texas: The importance of surgeons and health care professionals as advocates. Bull Am Coll Surg. 2019;104(11):31-34. Available at: bulletin.facs.org/2019/11/stopping-the-bleed-in-texas-the-importance-of-surgeons-and-health-care-professionals-as-advocates/. Accessed November 6, 2019.
‡Sutton JH. State legislatures consider surprise billing legislation in 2019. Bull Am Coll Surg. 2019;104(11):35-37. Available at: bulletin.facs.org/2019/11/state-legislatures-consider-surprise-billing-legislation-in-2019/. Accessed November 6, 2019.
