In 2023, state legislatures convened for the first full sessions since COVID-19. Overall, more than 104,000 state bills were introduced and 14,538 were enacted.
As the year comes to a close, all but seven state legislatures have either adjourned or will do so at the end of the year. With a considerable number of healthcare issues under consideration, the ACS continues to lead efforts to advance policies elevating surgical practice while advocating against proposals that undermine it.
State lawmakers have significant power in shaping policies and regulations directly affecting surgeons and their practice. State legislatures often serve as the testing ground for new initiatives that may be considered at the federal level as this environment is typically more accessible and responsive. In 2023, the ACS State Affairs team reviewed 5,823 bills, monitoring and tracking 877.
This article provides a brief overview of that legislation, which includes securing funding for trauma systems, STOP THE BLEED® initiatives, insurance coverage for cancer screening and diagnostic testing, prior authorization, tort reform, and the criminalization of physician care.
Trauma System Funding and Development
The 2023 state legislative sessions carried forward many of the trauma system legislative priorities from the previous year, including trauma system funding and advancing STOP THE BLEED initiatives. Notable achievements include Indiana’s SB 04, which established a state trauma care commission comprising 13 members of the Indiana Committee on Trauma (COT), and HB 1001, which allocated significant funding, specifically $3.3 million in fiscal year (FY) 2023/2024 and $5.8 million in FY 2024/2025 for the state’s trauma system (see Figure 1).
STOP THE BLEED
In 2023, progress was made in promoting STOP THE BLEED initiatives across the US. A total of 20 bills were introduced, and five states enacted legislation to ensure the availability of STOP THE BLEED kits and training, with more states considering similar measures (see Figures 2 and 3).
California ran a bill, AB 71, which amends existing law requiring the State Department of Education to make available on its website a list of resources and instructional materials on bleeding control, including training material developed by STOP THE BLEED for school districts. At the time this article was published, this bill was on Governor Gavin Newsom’s desk awaiting his signature.
Three states passed resolutions memorializing STOP THE BLEED month in May: Delaware, Michigan, and New York. The ACS is developing a toolkit with sample proclamation language and step-by-step instructions on how to request a proclamation from each state’s legislature.
Cancer Prevention, Screening, and Testing
Efforts to remove barriers to cancer care gained momentum in 2023, with a focus on eliminating cost-sharing for cancer screenings and exploring the role of biomarkers. The ACS closely tracked, monitored, and actively advocated for cancer-related bills, resulting in the passage of 12 bills aimed at enhancing cancer prevention and screening.
Prior Authorization and Utilization Review
Addressing insurance and administrative burdens remains a top priority. According to an American Medical Association (AMA) survey, prior authorization leads to delayed and abandoned care. The average physician practice completes 45 prior authorizations per physician per week, and doctors and their staff spend nearly 2 business days a week completing such authorizations.*
The ACS is working with the AMA and other national medical organizations to manage issues like prior authorization and utilization review. In the 2023 legislative session, the ACS tracked 95 bills in 30 states. These efforts sought to reform prior authorization processes, ensuring quicker responses and increased transparency. Twelve states successfully enacted legislation: Arkansas, Arizona, Colorado, Indiana, Maryland, Montana, North Dakota, Rhode Island, Texas, Virginia, Washington, and West Virginia.
The ACS is advocating for prior authorization reforms, including:
- Establishing quick response times (24 hours for urgent, 48 hours for nonurgent care)
- Allowing adverse determinations only by a physician licensed in the state and of the same specialty that typically manages the patient’s condition
- Prohibiting retroactive denials if care is preauthorized
- Making authorization valid for at least 1 year, regardless of dose changes; and for those with chronic conditions, the prior authorization should be valid for the length of treatment
- Requiring public release of the insurers’ prior authorization data by drug and service as it relates to approvals, denials, appeals, wait times, and more
- Requiring a new health plan to honor the patient’s prior authorization for at least 90 days
- Reducing volume through the use of solutions such as prior authorization exemptions or gold-carding programs
Tort Reform
Tort reform efforts continued in states such as New York, aiming to strike a balance between patient rights and professional liability concerns. The ACS, in collaboration with state chapters and other national medical associations, engaged in advocacy to address concerns related to tort reform legislation.
Earlier this year, New York Governor Kathy Hochul vetoed a bill that would have greatly expanded damages awarded in wrongful death action. Estimates demonstrated a substantial 40% increase in physician’s professional liability insurance.
A new version of the bill was introduced during the same session and was passed by the legislature, which unfortunately didn’t address any of the concerns raised by the New York ACS Chapter, the ACS, and the Medical Society of the State of New York (MSSNY), and the bill is awaiting action by the governor. The ACS is working with the state chapter and MSSNY to create talking points, fact sheets, and email action alerts asking the governor not to sign the bill.
Criminalization of Physician Care
The sensitive issue of the criminalization of physician care, which refers to any situation in which physicians can be fined, face licensure discipline or revocation, or in some cases arrested for providing healthcare or referring a patient to healthcare services in the state or out of state continues to be an issue the ACS actively monitors.
During the June 2023 AMA Annual Meeting, delegates discussed a resolution introduced by the American Society of Addiction Medicine (ASAM) calling on the AMA to study the rapidly changing environment in which the practice of medicine has been criminalized.
Stuart Gitlow, MD, MPH, MBA, the ASAM delegate, noted that the Controlled Substances Act requires physicians to prescribe controlled substances for legitimate medical purposes, but that the US Department of Justice views guideline departures—such as off-label prescribing—as not acting in the usual course of professional practice and, therefore, subject to indictment. As a result, he said that several prominent colleagues in several states have been raided, are under indictment, or are in prison.†
When US District Judge Robert L. Hinkle blocked a law banning the use of puberty blockers and hormone therapy to treat children diagnosed with gender dysphoria, the Florida Board of Medicine and the Florida Board of Osteopathic Medicine created new informed consent forms for transgender patients seeking gender-affirming care. Adults, children, and parents of kids who receive puberty blockers or hormone therapy must sign the forms. Doctors who violate the law face license revocation and felony charges.
Supporting State Chapters
ACS chapters are instrumental in shaping state healthcare legislation. In September, the State Affairs Workgroup was established, comprised of four prominent, advocacy-focused surgeons—Arnold Baskies, MD, FACS (NJ), Ali Kasraeian, MD, FACS (FL), Kevin Koo, MD, MPH, MPhil (MN), and Kelly Swords, MD, FACS (CA). This workgroup will play a critical role in identifying advocacy priorities, setting new policy objectives, and evaluating ACS state advocacy grant applications.
These grants can be used to support ACS chapters’ annual state advocacy days and other lobbying efforts and can help cover costs such as member travel, catering, venue rentals, and printing. Many states took advantage of this grant program in 2023, boosting interest and attendance at their advocacy day events.
The following 2023 meetings provided opportunities to advocate for meaningful change in healthcare legislation:
- AMA State Advocacy Summit
- Indiana State Advocacy Day
- Texas State Advocacy Day
- Florida STOP THE BLEED Training at the Capitol
- Annual COT Symposium
- Oregon State Advocacy Day
- ACS Leadership and Advocacy Summit
- California State Advocacy Day
- Ohio State Advocacy Day
- Wisconsin State Advocacy Day
- AMA State Advocacy Roundtable
- National Conference of State Legislatures Legislative Summit
- Massachusetts STOP THE BLEED Day at the Capitol
To help increase the impact of state advocacy days, the ACS is working on updating its State Advocacy Day Toolkit. The Toolkit will include detailed information on working with state legislators, choosing state legislative priority issues, determining the basic structure for the day’s schedule, recruiting participants, building educational materials, and preparing for legislative
appointments.
Additional state advocacy resources are available. In addition, the ACS State Affairs team is available to answer questions and provide background information regarding state issues and policy programs. For more information on how you can get involved in state advocacy efforts, contact Catherine Hendricks at chendricks@facs.org.
