Stateline

Vol. 26, No. 5 • May 2017

MidwestTHE MIDWESTERN OFFICE OF THE COUNCIL OF STATE GOVERNMENTS

INSIDE CSG Midwest Issue Briefs 2-3 Shoring up health exchanges • Criminal Justice & Public Safety: Illinois opens up professional licensing for ex-offenders • Agriculture & Natural Resources: Minnesota Premium hikes in 2017 led Minnesota to intervene with tax credit provides relief to farmers, help to schools • Passenger Rail: State, federal officials crafting funding for subsidies, reinsurance; all states face uncertainty plan for better intercity service in Midwest • Education: Indiana reduces class time spent on by Jon Davis ([email protected]) assessments, expands graduation pathways Around the Region 4 ast summer, as insurers filed their % change in Midwest health What happened? individual health insurance plan rate South Dakota at forefront of national effort to ‘kill insurance premiums for 2017 premiums for 2017, it became clear In 2014, as a central part of providing Quill,’ collect taxes from remote sales L that something was wrong: Rates in 31 coverage through the U.S. Affordable 7% MLC Chair’s Initiative 5 states shot up by double digits (triple Care Act of 2010, health insurance 59% exchanges opened up across the country Uptick in maternal death rates leads to new digits for Arizona); overall, the average 39% 16% — either run by states themselves, the Michigan law, proposal in U.S. Congress increase in premiums was 25 percent. 7% federal government or a combination In the Midwest, Minnesota was socked 51% 25% 2% of the two. Question of the Month 5 with a 59 percent increase that fur- 43% -3% Which Midwestern states impose additional or ther roiled an already shaky individual Because these exchanges created a special registration fees on electric vehicles? 42% health insurance market (or exchange). new way of providing and purchasing Legislators there responded earlier this health insurance, no one knew what to Profile 8 State’s increase was at or lower than expect, says Sara Collins, vice president Kansas House Speaker Ron Ryckman year by first providing help to those not the overall U.S. average increase of of The Commonwealth Fund’s health covered by federal subsidies and then cre- 25 percent care coverage and access program. Hence FirstPerson 9 ating a state-funded reinsurance program. State’s increase was higher than the South Dakota Sen. Deb Soholt on a new law in An analysis released in October by the overall U.S. average increase of 25 the federal reinsurance program, which her state to deal with the shortage of physicians Kaiser Family Foundation attributed the percent essentially provided insurance for the premium rate hikes across the country * Changes from 2016 to 2017 are based on premiums for insurance companies by having the CSG News & Events 10 to a combination of factors, including second-lowest-cost “silver” plan for a 27-year-old. government pay some portion of claims State legislators selected to lead bipartisan substantial losses experienced by many Source: The Fiscal Times (based on U.S. Department of Health & for the first two years of implementation committees of Midwestern Legislative Conference insurers in the individual market and the Human Services data) (from 2014 through 2016). Capitol Clips 12 phasing out of the federal reinsurance According to Collins, insurance car- program. Kaiser researchers also found would withdraw from the Iowa exchange riers now have a better understanding • Indiana raises gas tax to invest more in roads that due to losses in the individual mar- for 2018, possibly making that state the of how the markets work and, therefore, • Wisconsin seeks drug screening in Medicaid ket, the average number of participating first to have no insurers in most counties. have a more accurate sense of pricing, so • Nebraska looks to help mammography patients insurers dropped to 3.9 per state in 2017, So with some states’ individual ex- the 2017 premium spikes were basically • Iowa cracks down on texting while driving down from 5.4 in 2016 and 5.9 in 2015. changes in flux — and uncertainty over a pricing correction reflecting both that That trend looks to continue. Wellmark whether the U.S. Congress will repeal and and the phasing out of federal reinsur- Blue Cross/Blue Shield and Aetna both replace the Affordable Care Act — what ance payments. announced in April that they will pull out happened? And what lessons for Iowa Gary Claxton, vice president at the (and other states) might there be in how Kaiser Family Foundation and director Stateline Midwest is published 12 times a year of Iowa’s exchange in 2018, leaving Medica by the Midwestern Office of Insurance Co. as the only available insurer Minnesota dealt earlier this year with the of its Healthcare Marketplace Project, The Council of State Governments. in all but five of the state’s 99 counties. problems in its state exchange? agrees. “There’s reason to believe that Annual subscription rate: $60. Wellmark’s president, John Forsyth, PLEASE TURN TO PAGE 6 To order, call 630.925.1922. told The Des Moines Register that his company has lost $90 million over the last Premiums for individual three years, and that the “overall problem health insurance policies is too few healthy, young consumers are sold in state and federal buying health insurance,” and that the exchanges skyrocketed U.S. Affordable Care Act’s penalty for from 2016 to 2017. CSG Midwestern Office Staff individuals refusing to buy insurance Experts say that was Michael H. McCabe, Director “hasn’t been enough to goad many young fueled by the planned Tim Anderson, Publications Manager consumers into the pool.” phasing out of a federal Jon Davis, Assistant Editor/Policy Analyst Iowa Insurance Commissioner Doug reinsurance program and Cindy Calo Andrews, Assistant Director a better understanding Ilene K. Grossman, Assistant Director Ommen concurred in an April 6 state- Lisa R. Janairo, Program Director ment: “This is a problem created by the of the makeup of Laura Kliewer, Senior Policy Analyst Affordable Care Act and needs to be fixed exchange markets. But, Gail Meyer, Office Manager what comes next? Laura A. Tomaka, Senior Program Manager in Congress.” Kathy Treland, Administrative Coordinator and Meeting Planner In early May, Medica said it, too, Katelyn Tye, Policy Analyst CSG MIDWEST ISSUE BRIEFS

Issue Briefs cover topics of interest to the interstate groups and policy committees of CSG Midwest, including the Midwestern Legislative Conference, Great Lakes Legislative Caucus, Midwest Interstate Passenger Rail Commission and Midwestern Radioactive Materials Transportation Committee. Criminal Justice & Public Safety

Nationwide, many state laws on occupa- Illinois legislation looks to # of adults released from correc tional reduce employment barriers for tional and business licensing exclude applicants with facilities in Midwest, 2015 felony convictions. The American Bar Association people with criminal histories documents an estimated 32,000 licensing laws that ach year in Illinois, around 30,000 adults return 1,525 include consideration of an individual’s criminal home from state correctional facilities, many in 7,669 record; of these, more than one-third automatically Esearch of jobs. To reduce employment barriers 2,764 5,553 exclude felons, The Council of State Governments for people with criminal records, lawmakers have 13,728 Justice Center notes in a 2015 study. changed the way Illinois’ professional licensing 5,522 “It’s like people are serving an additional 2,358 body reviews applications for certain occupations. 21,759 sentence outside of jail or probation,” Evans says. 16,225 Under a law enacted last year, the state Department 29,732 This year, Evans has introduced two bills (HB 2752 of Financial and Professional Regulation must now 5,950 and 3822) that would create a similar licensing process consider “mitigating factors” surrounding a criminal for more than a dozen additional occupations, includ- conviction before denying an application for eight Source: U.S. Bureau of Justice Statistics ing dance hall managers, landfill operators, livestock occupations: funeral directing and embalming; dealers and insurance agents. These measures would barbering; cosmetology; esthetics; hair braiding; Evans, who sponsored the legislation (HB 5973) in require the state to provide written notice to license ap- nail technology; and roofing. 2016. He hopes the new review process will attract plicants who are denied based on their criminal history. The mitigating factors include whether the people who may have been deterred from applying Also under consideration are HB 3342, which individual’s criminal offense would have any for a license in the past. would reduce licensing barriers for health care work- impact on his or her fitness for the occupation, “A lot of folks didn’t even have the courage to ers, and HB 3395, which would do so for emergency how much time has elapsed since the conviction, apply because they assumed they would be denied medical technicians, acupuncturists, athletic trainers, and the person’s age at the time of the conviction. based on their background,” Evans says. social workers, dietitians and nurse practitioners. Prior to the law’s passage, license applications To track the law’s impact, the department must At least four other states in the Midwest from people with criminal histories would either report annually (starting next year) on the number (Michigan, Minnesota, North Dakota and Ohio) have be denied outright or be left pending for an of applicants with criminal convictions who were adopted laws in recent years to improve licensing indeterminate amount of time, says Rep. Marcus granted and denied licenses in the eight occupations. opportunities for people with criminal records.

Brief written by Katelyn Tye, CSG Midwest staff liaison to the Midwestern Legislative Conference Criminal Justice and Public Safety Committee. She can be reached at [email protected]. The committee’s co-chairs are Illinois Sen. Mattie Hunter and Ohio Rep. Nathan Manning.

Agriculture & Natural Resources

thousand dollars in additional taxes over the life Minnesota tax credit provides Real estate taxes as share of farm of a 30-year construction bond. According to the relief to farmers, greater chance property values, expenses (2015) Minnesota Farm Bureau, farmers in some agriculture- for rural schools to build Taxes as share of Taxes as share of rich school districts are required to pay up to 10 times State n Minnesota, the chances of a local school as much as other taxpayers in those same districts. property values production expenses district getting the money it wants to build a The Ag2School credit would apply to all current Illinois 0.31% 3.2% new facility or improve existing buildings can and future capital referendums, Minnesota Rep. Paul I Indiana 0.49% 4.0% depend greatly on where it is located: In metropoli- Anderson says. If a farmer’s levy for a school building tan areas, most school construction projects get referendum was $25 per acre, for example, the state Iowa 0.38% 2.1% approved by local voters; in rural districts, these would provide him or her with a credit of $10 per acre Kansas 0.64% 2.9% proposed tax increases tend to fail. (40 percent). He adds that the measure has bipartisan Michigan 0.89% 4.6% This discrepancy led to legislative action this year. support, and would have become law last year if not As envisioned under a section of HF 4 (Minnesota’s for a “one-word error” that led to a gubernatorial veto. Minnesota 0.51% 3.6% omnibus tax bill that still needed final approval as According to the Minnesota Rural Education Nebraska 0.94% 5.4% of early May), new state tax credits would offset 40 Association, about half of the state’s schools were built North Dakota 0.33% 2.6% percent of a school district’s bond debt load that is before 1976, and 25 percent are between 54 and 125 attributed to agricultural property-tax payers. Some years old. School buildings have a 60-year life span. Ohio 0.58% 4.3% 240,000 parcels of land would qualify for the credit. Over the past 20 years, Minnesota has reduced its South Dakota 0.35% 3.9% By providing relief to farmers, lawmakers hope assistance to local districts for school construction that this group of local taxpayers will be more likely funding. In the 1990s, the state paid about 11 percent Wisconsin 0.66% 3.6% to vote “yes” on local referenda and less burdened by of the debt-service costs for local districts, but its share Source: U.S. Department of Agriculture the costs of approved school projects. has dropped to about 3 percent today. At the same In some districts, farm families make up only a time, Minnesota farmers have seen more than a 150 on its agricultural value rather than its market value small percentage of the taxpayers and a local school’s percent increase in their property tax levies since 2005. (the property would be valued higher for residential students, but their land accounts for a majority of Minnesota’s main method of providing tax or commercial use). When farmland is sold for the tax base that must pay for a project. As a result, relief to farm producers is through Green Acres, a residential or commercial use, the deferred tax for the individual farms may wind up paying several hundred tax-deferral program that assesses farmland based prior two years must be paid to the county.

Brief written by Carolyn Orr, staff liaison to the Midwestern Legislative Conference Agriculture & Natural Resources Committee. She can be reached at [email protected]. The committee’s co-chairs are Iowa Sen. Kevin Kinney and Minnesota Rep. Paul Anderson; its vice chair is Illinois Rep. Norine Hammond.

2 STATELINE MIDWEST MAY 2017 Passenger Rail

Federal study seeks long-term intercity service? What are the funding options framework for improving and strategies? What kind of governance model Amtrak routes in the Midwest in 2017 intercity rail service in Midwest could states in the Midwest employ? These are among the questions state and federal officials he Federal Railroad Administration has will explore as they “produce a 40-year framework formally launched an 18-month study that for the Midwest intercity passenger rail network.” Tis exploring the long-term development of The regional study began in March with a high-performance, intercity passenger rail service workshop in Chicago; the next meeting will be for the Midwest. held June 7 in St. Paul, Minn., and will focus in This project’s roots date back to the U.S. Passenger part on governance issues. Rail Investment and Improvement Act of 2008 and The FRA’s lead stakeholders in this planning that law’s call for “a long-range national rail plan.” process are MIPRC and 12 state departments of Such a plan, in turn, relies on regional coordination. transportation in the Midwest. The 18-month In 2011, for example, the FRA conducted a study also includes participation by local govern- study of the Southwest in which it developed a ments, metropolitan planning organizations, Developed by the region’s state departments “toolkit” for use in regional planning efforts. railroads, public and private passenger rail of transportation, the Midwest Regional Rail At the same time, the Midwest Interstate Passenger operators, transit agencies, and advocacy groups. Initiative envisions a 3,000-mile, nine-state pas- Rail Commission (MIPRC) and the Midwest Regional “MIPRC is excited to work with the FRA senger rail system with Chicago as its hub — with Rail Initiative began talks with federal officials. These and the region’s departments of transportation, fast, frequent service on eight improved and new two groups proposed a series of workshops that would and local leaders, to develop the version of our corridors connecting some of the region’s largest help identify the institutional, financial, political long-term strategy for intercity passenger rail cities. and regulatory structures that the Midwest needs to in the Midwest,” says Tim Hoeffner, the chair of This plan has served as the blueprint for most improve intercity passenger rail service. MIPRC and director of the Michigan Department of the Midwestern states’ applications to the On behalf of the region, MIPRC submitted a of Transportation’s Office of Rail. federal High Speed Intercity Passenger Rail grant formal proposal for an FRA-led study in 2014. (CSG “Starting with the development of the Midwest program. Under this program, the Midwest was Midwest provides staff support to MIPRC.) Regional Rail Initiative plan in the ‘90s, the awarded $2.5 billion between 2009 and 2011. What rail corridors and investment projects Midwest has been leading regional intercity pas- For more about the Midwest Regional Rail should be prioritized in order to strengthen senger rail planning.” Planning Study, visit www.midwestrailplan.org.

Brief written by Jon Davis, a CSG Midwest policy analyst, who can be reached at [email protected]. The Midwest Interstate Passenger Rail Commission was formed by an interstate compact agreement; it currently has nine member states. Tim Hoeffner, director of the Michigan Department of Transportation’s Office of Rail, serves as MIPRC chair. More information is available at www.miprc.org.

Education

Indiana lawmakers replace Type of statewide test used to assess through eighth-graders, and students will take three unpopular ISTEP+ with new 3rd- to 8th-graders in math and statewide assessments in science during their K-12 statewide assessment system English-language arts* careers. HB 1003 ends elementary-level assessments in social studies while requiring that students be t a time of general wariness across the assessed once on U.S. government or history. country regarding the use of standardized Previously, students had taken the ISTEP at different Atests in schools (54 percent of respondents times of the year; I-LEARN will only be administered to a 2015 national survey said they are “not help- statewide at the end of the school year. That single ful”), Indiana lawmakers have tried to deal with testing window, along with less overall testing time, a particular problem in their state. should address at least some of the concerns raised by “It came to a point where the ISTEP had become educators, parents and students, Behning says. like the Ford Edsel,” Indiana Rep. Bob Behning says. At the high school level, meanwhile, I-LEARN ISTEP+ is Indiana’s statewide assessment system, provides students with new pathways to graduation. and over the past few years, its unpopularity grew Gone are the requirements that young people pass end- amid reports of long delays in getting results, software Multistate/consortium assessment is of-course exams in Algebra I and 10th-grade English. glitches, scoring errors, and concerns about the administered** While these exams will remain in place, passing them amount of classroom time being spent on the test. will be only one way to meet graduation requirements. State-specific/non-consortium assessment Last year, the Indiana General Assembly passed is administered Other options will include achieving a certain a bill ensuring that ISTEP+ would indeed go the way Mix of consortium/state-specific assessment score on the SAT or ACT or passing international of the Edsel. This year, under a bill signed into law in is administered** baccalaureate and advanced placement exams.

April (HB 1003), lawmakers set parameters for a new * Federal law requires y early testing of students in these grades and subjects. Also under the new law, school districts will have assessment system, which will be known as I-LEARN ** Multistate/consortium assessments used are the PARCC test (by Illinois) and more flexibility on how to use results from statewide as- and take effect during the 2018-19 school year. Smarter Balanced Assessment (by North Dakota, South Dakota and Michigan). sessments to evaluate teachers. Legislators, meanwhile, Implementation of I-LEARN has been left to Sources: Education Commission of the States and Education Week may further study this contentious topic (linking test the state’s school superintendent and 11-member results to teacher performance) during the interim. Board of Education, but Behning says HB 1003 of the legislation and member of the panel. “We wanted Lastly, the new law prioritizes what it calls “as- reflects the priorities of legislators and an advisory it to involve educators as much as possible, and to have sessment literacy skills.” For example, it calls on the panel they created in 2016. something that is of high quality but less expensive.” Indiana Department of Education to improve parents’ “We needed to have an assessment that is shorter, As required by federal law, Indiana will continue and teachers’ understanding of statewide assessments with a single testing window,” says Behning, a sponsor yearly assessments in math and reading for third- and how the results can be used to improve instruction.

Brief written by Tim Anderson, CSG Midwest staff liaison to the Midwestern Legislative Conference Education Committee. He can be reached at [email protected]. The committee’s co-chairs are North Dakota Sen. Kyle Davison and Kansas Rep. Melissa Rooker; its vice chair is Wisconsin Rep. Eric Genrich.

STATELINE MIDWEST MAY 2017 3 AROUND THE REGION

Proposals to expand Two Midwest states join South sales tax base stall in Nebraska and Ohio Dakota with ‘Kill Quill’ laws; goal llinois, Nebraska and Ohio are among the states is to collect remote sales taxes this year where legislators have considered plans to expand the reach of their sales tax I quarter-century has passed since a U.S. provide the direction that states need to move systems, but as of early May, none of the measures Supreme Court decision limited the ability forward with tax collections in an orderly way. appeared close to passing. of states to collect taxes from the remote In April, bipartisan bills were once again intro- These proposals would capture more of the A sales of out-of-state retailers. duced in the U.S. House (HR 2193) and Senate (SB economic activity in a state’s service economy. Legislators wanting to secure that taxing au- 976). Under these proposals, states meeting one of They can be used as way to boost state revenue or thority — which they say is critical to maintaining two criteria could compel remote sellers to collect as part of broader plans to cut taxes in other areas. state revenue bases and helping brick-and-mortar sales and use taxes: 1) The state is a member of Ohio Gov. John Kasich has proposed reducing businesses — believe a reversal of Quill Corp. v. the Streamlined Sales and Use Tax Agreement, or the state’s income tax rate. To pay for it, he wants North Dakota may finally be on the horizon. 2) The state has adopted minimum simplification to raise the rate of the sales tax (from 5.75 percent “I do believe Quill will get overturned; it’s requirements as outlined in the federal legislation. to 6.25 percent) and add several services to the just a matter of time,” North Dakota Sen. Dwight base — for example, cable subscriptions, travel Cook says. States waiting, and acting services, and cosmetic surgery that is not medi- And one of the U.S. states most cally necessary. However, a budget approved by the Ten of the 11 Midwestern states reliant on the sales tax as a revenue E-commerce sales Ohio House in early May did not include Kasich’s (all but Illinois) already have source, South Dakota, might bring in U.S as % of proposed changes, according to The (Cleveland) passed legislation conforming to the case that “kills Quill.” total retail sales Plain Dealer. the Streamlined Sales and Use Tax A year ago, South Dakota law- Year Percent Nebraska’s LB 452 calls for taxing a host of Agreement. By providing more makers passed a bill requiring most services: dry cleaning and laundry; taxi and 2006 3.1% administrative uniformity among retailers without a physical presence limousine transportation; tanning; and hair, nail states and using new software in the state to remit the state’s sales 2007 3.5% and skin care. The bill, which also would reduce and technology, the multistate tax. SB 106 applies to sellers with 2008 3.6% individual and corporate income tax brackets, agreement simplifies sales and 200 or more annual transactions failed to advance out of committee this session. 2009 4.2% use tax collections for retailers, in South Dakota or whose gross In Illinois, discussions over a “grand bargain” particularly those operating in revenue from sales in the state 2010 4.6% to solve the state’s long-standing budget problems multiple states. exceed $100,000. This year, Indiana have included expanding the sales tax base to 2011 5.1% The U.S. Senate passed a ver- (HB 1129) and North Dakota (SB include landscaping, personal care services, cable 2012 5.5% sion of the Marketplace Fairness 2298) passed “economic nexus” laws television and building repairs, Crain’s Chicago Act in 2013, but the legislation of their own. 2013 6.1% Business reported in May. stalled in the House. The South Dakota law was The extent to which services are taxed 2014 6.6% “Every year, we are constantly immediately challenged and is varies widely among the 50 states. In its most working with members of Congress currently in the hands of the state 2015 7.6% recent nationwide analysis, the Federation of Tax to get this done,” Peters says. Supreme Court — but maybe not for 2016 8.3% Administrators found that South Dakota taxed 146 Opposition has come from long. Sen. Deb Peters, the sponsor different services. That is far more than any other Source: Federal Reserve Bank of St. members who view the legislation as of SB 106, hopes justices in her state Louis and U.S. Census Bureau state in the Midwest. Iowa was taxing the second- a tax increase or who prefer a differ- send the case to the U.S. Supreme highest number of services (94), the FTA analysis ent approach than that proposed in Court, perhaps in time for Quill to found, while Illinois was capturing the smallest the Marketplace Fairness Act — for be re-examined during its next term. number of services (17) in its sales tax base. example, basing the sales tax on the location of the Language in the final version of SB 106 makes seller rather than the buyer and requiring states to clear the high stakes surrounding Quill for South have a single rate for all remote sales. S Dakota, a state that has no income tax and relies on Even minus federal action, states have taken sales taxes for more than half of its revenues. The steps to improve tax collections from remote sales. measure also references the words of U.S. Supreme One common approach has been to require sales Court Justice Anthony Kennedy in a 2015 opinion. 27.4% tax collections by an online retailer who has some “It is unwise to delay any longer a reconsid- 22.2% kind of “physical presence” in the state, including eration of the court’s holding in Quill,” Kennedy 55.4% in-state sales “affiliates” who sell products via the 28.7% wrote, noting both “the dramatic technological and 33.4% retailer’s’ website. social changes … in our interconnected economy” 33.1% Most recently, the Massachusetts Department of 34.9% and a “startling revenue shortfall in many states.” 42.6% Revenue directed large, out-of-state Internet vendors 24.8% 41.5% The U.S. Supreme Court’s newest justice, Neil to begin collecting and remitting the state’s sales Gorsuch, also has argued that the Quill decision 40.2% or use tax. Its argument: All of these vendors have should be revisited, The Hill reported in May. an “in-state presence” because of the very nature “At this point, my bet is that the court will deal Source: Federation of Tax Administrators of how remote sales take place. These transactions with this before the U.S. Congress does,” says Stacy involve software downloaded to the devices of S Mitchell, co-director of the Institute for Local Massachusetts customers and the “cookies” (data Self-Reliance. That is not only because of Congress’ text files) stored on these in-state devices. 5.0% busy legislative agenda this year, she adds, but In the 1992 Quill case, the U.S. Supreme Court because of its history of inaction on this issue. 6.875% decision was based on the mail-order sales of office 4.5% 5.0% ‘Ultimate goal’ is congressional action equipment and supplies from a Delaware company 6.0% to customers North Dakota. 6.0% In its 1992 decision, the U.S. Supreme Court said “The landscape is entirely different today than 5.5% 6.25% 7.0% 5.75% Congress has the authority to decide “whether, it was back then,” Cook says. when and to what extent” states can compel 6.5% out-of-state sellers to collect sales and use taxes. Article written by Tim Anderson, CSG Midwest publica- “The ultimate goal is to get Congress to act,” tions manager. He can be reached at [email protected]. Source: Tax Foundation Peters says, because the federal legislation would

4 STATELINE MIDWEST MAY 2017 MLC CHAIR’S INITIATIVE

Michigan law reflects concerns about trends in maternal deaths

by Tim Anderson ([email protected])

ake a look at the longer-term trends in deaths are increasing, and concerns about that trend Maternal mortality ratios per maternal mortality rates, and you see one of led to this year’s passage of HB 4235. It took effect in 100,000 live births (2005-2014) Tthe great success stories in modern-day public April, and now requires physicians and hospitals to health: In 1900, for every 1,000 live births, up to nine report the death of a woman who was pregnant at the women were dying of pregnancy-related complica- time of death or within one year before her death. 18.0 tions; a century later, that rate had “Some of the data was com- 11.8 declined by almost 99 percent. ing in late, and some wasn’t 18.3 14.5 But the story told by more recent MLC Chair’s Initiative: being reported at all,” says Amy 23.3 data is less clear, and more troubling. Healthy Birth Outcomes in Zaagman, executive director 11.6 the Midwest 14.4 of the Michigan Council for 18.4 According to the U.S. Centers 12.4 21.7 of Disease Control and Prevention, Maternal and Child Health. the number of reported pregnancy- The new mandate, Zaagman 16.8 related deaths increased between says, will ensure that health 1987 and 2013 — from 7.2 deaths per professionals and lawmakers Source: Preeclampsia Foundation (using data from September 2016 article in 100,000 live births to 17.3 in 2013. have the information they need Obstetrics & Gynecology) Better reporting (for example, the to make appropriate changes in addition of a pregnancy check box medical practice and policy. As HB 4235 made its way (Michigan, for example, has the nation’s longest- on state death certificates) is one explanation for running Maternal Mortality Review Committee.) the increase. Another reason, though, may be that through the Legislature last year, lawmakers learned not only about the rise in reported deaths from In her conversations with Michigan legislators, pregnancy-related deaths are actually on the rise. The Zaagman points to several other state policies that pregnancy, but about how it is disproportionately CDC notes, for example, that more pregnant women can make a difference for pregnant women and impacting certain areas and populations. have conditions such as hypertension, diabetes and their babies — for example, investing in home- For example, African American women in chronic heart disease that may put them at a higher visiting programs and improving access to and use Michigan are more than three times likely to die from risk of complications. of contraception (including long-acting reversible pregnancy complications as white women (the same Globally, the United States ranks about 50th for contraceptives). Intended pregnancies, she says, are is true nationally), and Zaagman says rates of death its maternal mortality rate, and last September, a s safer for mothers and their babies. are especially high in cities such as Detroit and Flint. Journal of Obstetrics and Gynecology study concluded These racial disparities also are being high- that pregnancy-related deaths are rising across the This article was written as part of this year’s Midwestern lighted by congressional sponsors of The Preventing country. Legislative Conference Chair’s Initiative of Iowa Sen. Maternal Deaths Act. Introduced in March, the Janet Petersen. This initiative, Healthy Birth Outcomes, Data needed to drive better policy federal legislation would provide states with grants is examining ideas to improve the health of mothers and to establish maternal mortality review committees, their babies. Michigan is among the states where reported maternal or improve the work of these existing groups.

QUESTION OF THE MONTH

year, electric vehicle owners in Michigan are being QUESTION: Which Midwestern states impose additional or special assessed a $100 annual surcharge, along with a registration fees on electric vehicles? $35 gasoline tax, in addition to the state’s standard vehicle-registration fee (which is about $120). Michi- gan’s extra fees on electric vehicles were part of a With a rise in the sale of electric vehicles, states lose 2015 legislative package that provided $1.2 billion some of the revenue that they’ve long relied on to # of plug-in-vehicle registrations per 1,000 people in road construction funding and raised the state’s pay for transportation projects: taxes on motor fuels. standard vehicle-registration fees by 20 percent. One response by some legislatures, in the Midwest and around the country, has been to impose addi- 0.15 Across the country, state fees on electric vehicles tional registration fees on the owners of these cars. range anywhere from $50 (Colorado and Wyoming) 0.54 to $200 (Georgia). Proponents of these add-on fees At the start of this year, 10 U.S. states already were 0.22 0.59 argue that electric vehicles contribute to the wear 0.99 imposing extra registration fees, and Indiana be- and tear of a state’s transportation infrastructure, came the 11th in April with passage of HB 1002. 0.38 0.37 and because these cars don’t use gas and their own- Starting in 2018, the owners of electric vehicles will 0.45 0.67 0.41 ers don’t pay taxes on motor fuel, the fees help to pay an annual registration fee of $150; the fee for recoup at least some of the lost revenue. hybrid vehicles is $50 a year. HB 1002 also includes 0.35 a $15 annual infrastructure fee on every vehicle and Many states, meanwhile, also provide incentives for increases the state’s gas tax (for the first time in more the purchase of environmentally friendly electric than a dozen years) by 10 cents per gallon. *Among the 50 U.S. states, California has the highest concentration of vehicles — from rebates on purchases, to access to plug-in vehicles: 4.68 per 1,000 people high-occupancy-vehicle lanes, to lower electric rates During this year’s legislative sessions, lawmakers in Source: U.S. Department of Energy’s Oce of Energy Eciency & Renewable Energy for charging these cars, according to the advocacy at least two other Midwestern states, Minnesota and group Plug in America. In Illinois, the owners of elec- Kansas, also considered new fees on electric vehicles. tric vehicles pay a lower registration fee — $18 for Minnesota’s HF 1133/SF 2029, for example, calls for sidered, but ultimately failed, to enact extra registra- one year, compared to $101 for a motor-fueled car. a surcharge of $85. In Kansas, HB 2060 would have tion fees on electric vehicles include North Dakota, required an additional $150 fee on electric vehicles South Dakota and Wisconsin. Article written by Laura Tomaka ([email protected]), a CSG ($75 on hybrid vehicles); it stalled in legislative Midwest policy analyst. Question of the Month highlights Nebraska was the first state in the Midwest to im- committee. an inquiry sent to the CSG Midwest Information Help Line: pose such a fee, with owners of these cars having [email protected] or 630.925.1922. Other Midwestern states that have previously con- to pay an additional $75 annually. Beginning this

STATELINE MIDWEST MAY 2017 5 COVER STORY

CONTINUED FROM PAGE 1 Minnesota fix, Iowa in a fix: State options to shore up health exchanges

rates are in the right place,” so future rate hikes statewide insurer, people would shouldn’t be quite as steep, he says. have to buy insurance outside How individuals in each Midwest state got There’s not a lot states can do about the 2017 the exchange, which means they their health insurance in 2015 (%-point rate hikes — “this is what insurance costs” — but would be forced to do so without change from 2013 in parentheses) some steps do help stabilize a state exchange for subsidies, says University of Iowa Non- State Employer Medicaid Medicare Uninsured future years, Claxton says. professor Keith Mueller, direc- group* For example, Medicaid expansion helps tor of the Rural Policy Research because it means more chronically ill people are Institute Center for Rural Health Illinois 54% (+1) 6% (+1) 19% (0) 14% (+2) 9% (-1) covered through this public health insurance Policy Analysis. Indiana 52% (+2) 5% (+1) 19% (+3) 14% (+1) 9% (-4) program rather than through private plans offered Finding a solution is “the on the exchanges. $64,000 question” for Iowa, says Iowa 53% (-4) 8% (+3) 17% (+2) 15% (+2) 5% (-3) In the Midwest, seven states — Illinois, Abigail Barker, a researcher with Kansas 54% (0) 7% (+2) 13% (-2) 13% (0) 10% (0) Indiana, Iowa, Michigan, Minnesota, North the center and a professor at Dakota and Ohio — already had adopted Medicaid Washington University in St. Michigan 53% (-1) 6% (+3) 19% (+2) 16% (+2) 6% (-5) expansion, agreeing to cover people up to at least Louis. Minnesota 56% (-4) 8% (+2) 14% (0) 15% (+2) 6% (-3) 133 percent of the federal poverty level (participat- Given the time and legislative ing states can opt to cover people above that level). approval needed to create a rein- Nebraska 55% (-2) 7% (0) 13% (+1) 13% (+2) 8% (-3) The federal government funded 100 percent of surance program, she says, that expansion costs from 2014 through 2017, and will strategy “might not help much in Ohio 52% (0) 5% (+2) 21% (+5) 15% (0) 6% (-6) gradually reduce that to 90 percent by 2020. 2018, but it might be a longer-term North Dakota 57% (-1) 8% (-1) 10% (-6) 14% (-1) 8% (-3) Although Wisconsin did not participate in solution,” she says. Medicaid expansion, it does cover adults up to Although some rural areas are South Dakota 53% (0) 9% (+1) 14% (+2) 14% (0) 9% (-1) 100 percent of the federal poverty level through doing better than others, Barker Wisconsin 55% (-1) 6% (+2) 17% (-1) 14% (0) 7% (-2) its BadgerCare Plus program. says, a fundamental problem is Kansas legislators approved a Medicaid expan- their low population density: Note: This table does not include other public insurance programs such as military or Veterans Administration coverage, so state totals may not add up to 100 percent. sion earlier this year, but in April, they narrowly There just aren’t enough people * Non-group coverage is defined as individuals and families that bought or are covered as a dependent failed to override Gov. Sam Brownback’s veto, to provide a robust individual by non-group insurance. falling three votes short of the two-thirds major- market, she says. Source: Kaiser Family Foundation (from U.S. Census Bureau’s Current Population Survey) ity needed in the House. (This policy issue was Tim McBride, another re- scheduled to be revisited in May.) searcher at the Center For Rural Health Policy Reinsurance programs help stabilize such mar- But even with Medicaid expansion, some Analysis and professor at Washington University, kets and “gives insurance companies knowledge individuals who don’t qualify for public health says possible ways around the problem of low of what their loss cap will be,” says Minnesota insurance, and don’t get coverage through their population density include Sen. Gary Dahms, who is a former owner of an employers, rely on the individual exchanges. This • redrawing local rating areas (state-designated insurance agency. becomes a problem in states or counties where geographic areas that are one permissible factor “It’s a model that’s known and has proved to the choice of insurers is limited, or where there is insurance companies can use to set rates), work in many different lines of insurance,” he adds. only one insurer. • creating statewide or nationwide plans open Minnesota’s woes began This problem is especially prevalent in rural to anyone, or in 2015 when PreferredOne areas because of small population sizes and a lack • recognizing that the exchange markets as pulled out of the state’s health of extensive networks of providers (hospitals, currently structured are failing for rural areas exchange, which is known as clinics, and practitioners). and will need better or more-targeted subsidies. MNsure. “That’s really difficult to figure out [how to PreferredOne had entered fix],” Claxton says. How reinsurance works the health-insurance market Reinsurance, which provides payments to or now, some form of reinsurance appears to in 2014 with some of the low- insurers to help offset the costs of enrolling higher- Minnesota Sen. be one of the more viable options to shore up est rates in the country, and Gary Dahms cost individuals, has been one strategy used under state health exchanges by better spreading it soon captured 59 percent the ACA and is now being tried in states such as F risk. It works, roughly, like this: of Minnesota’s exchange cus- Minnesota. When a consumer buys a $5 million insurance tomers. The company’s low rates, however proved This may be one policy option for Iowa as well. policy on a house, for example, the insurance unsustainable when they didn’t bring in enough If Medica leaves and Iowa is left without a single company issues the policy, and then has a portion people to cover the flood of new MNsure enrollees. of it reinsured (usually with a company special- Minnesota is the first Midwestern state to fund Midwest states and Medicaid izing in reinsurance). If the house burns down, a reinsurance program to stabilize its exchange expansion under A ordable Care Act the insurance company isn’t on the hook for the and attract insurers. Passed on March 30, HF 5 entire $5 million. establishes a $542 million program for two years; Under Minnesota’s new reinsurance law, it sets annual appropriations of $200 million the “attachment point model” will be used; for from the state’s “health care access fund” and $71 example, once an insurance provider has paid million from the general fund. *** out $50,000 worth of coverage, reinsurance kicks Money for the state’s health care access fund in and covers 80 percent of costs up to $200,000, comes largely from a tax on health care providers at which point the original insurer again bears and a tax on insurance premiums. all costs. Minnesota legislators had previously passed HF The states of Alaska and Minnesota have 1 in January, allocating $311.9 million from budget funded reinsurance in their health exchanges reserves to provide eligible residents a subsidy of for different reasons. With a population of only 25 percent of the monthly gross premium in the State has adopted Medicaid expansion 738,432, Alaska just doesn’t have enough people state’s individual market. Those who already get State has not adopted Medicaid expansion to sustain much insurer interest. By providing the ACA’s advance premium tax credits or who reinsurance for high-cost cases, the state helped are enrolled in public program coverage are not *** Wisconsin does cover adults at or below 100 percent of the federal reduce the 2017 rate increase sought by its only eligible. poverty level but has not adopted Medicaid expansion under the Aordable Care Act. insurer, Premera, from an estimated 42 percent With HF 1, the Legislature also allocated $15 to 7.3 percent. million to cover transition care for people with

6 STATELINE MIDWEST MAY 2017 FEATURE STORY

new health plans but who are continuing treatment only insurer in Alaska’s exchange filed rates for were all too low,” she says. “We’ve been playing for serious conditions, life-threatening mental or premiums that rose 7.3 percent, as opposed to the catch-up.” physical illnesses, and pregnancy 42 percent originally estimated. Moreover, Blewett says insurers still can’t get a good grasp of the individual exchange market’s beyond the first trimester. Number of people Idaho authorized a reinsur- risk profile because it keeps changing; the state’s Effective through June of next who chose plans in ance program last month, and in high-risk pool was folded into it, and now, some year, HF 1 includes other changes state exchanges (as Oklahoma — where premiums as well, such as permitting for- of Jan. 31) jumped 76 percent — a state task large employers in Minnesota are moving their profit HMOs to join the state-run force has recommended reinsur- pre-retirement employees into the market (and State Total individuals individual marketplace and al- ance in a 60-page plan to deal providing them with money to purchase policies lowing hospitals and clinics to Illinois 356,403 with skyrocketing premiums. on the exchange). Having the state act as the reinsurer does cost use administrative law judges Indiana 174,611 “Reinsurance always makes a to challenge the way insurance certain amount of sense if you’re some money, “but it gives stability to the market Iowa 51,573 providers select their networks. It willing to fund it,” Claxton says. and draws insurers back [to it],” Blewett adds. also paves the way for agricultural Kansas 98,780 If other states want to follow Minnesota’s lead, cooperative health plans to provide ‘Playing catch-up’ Sen. Dahms recommends laying the groundwork Michigan 321,451 via close cooperation among legislators, the insurance to farmers and agribusi- Minnesota 109,974 ahms, assistant majority governor’s office, and state and federal officials to ness employees. leader in the Minnesota ensure everyone is on the same page. Minnesota Gov. Mark Dayton Nebraska 84,371 Senate, says reinsurance Also, he says, know what the Section 1332 signed HF 1 (the subsidies for D North Dakota 21,982 was necessary because his state’s waiver process entails, and work with the U.S. consumers) in January and allowed Ohio 238,843 individual market had essen- Centers for Medicare and Medicaid Services to HF 5 (reinsurance for insurers) to tially collapsed. know what’s possible through that process before South Dakota 29,622 become law without his signature. Reinsurance was the best crafting a state reinsurance program and waiver In a statement, he voiced con- Wisconsin 242,863 — and quickest — solution application for it. cerns about the reinsurance legisla- Source: Kaiser Family Foundation to provide stability and draw According to the U.S. Department of Health and tion, saying it subsidizes insurance insurers back into that market, Human Services’ website, if a state can demonstrate companies without assurances from thus restoring competition and savings via a reinsurance program, a successful them that they will participate in Minnesota’s market consumer choice, he says. application for a Section 1332 waiver could allow or any indication that rates would be lowered in 2018. Lynne Blewett, professor of health policy and the state to get federal “pass-through” funding to But he agreed that state intervention was needed “to management at the University of Minnesota’s School offset part of that program’s costs. try and induce [insurers’] participation in Minnesota’s of Public Health, says reinsurance should help Section 1332 authorizes the secretaries of Health individual market in 2018 at the lowest possible rates.” stabilize Minnesota’s individual exchange market, and Human Services and Treasury to waive provi- Outside the Midwest, Alaska’s reinsurance which was underpriced and had lots of volatility sions under their respective jurisdictions related to program is being funded by a 2.7 percent tax on from the start. premium tax credits and cost-sharing reductions for all insurers. After the bill was passed last June, the “We had the lowest premium rates and they plans offered within the marketplaces.

The American Health Care Act: Its potential impact on health consumers, states On May 3, the U.S. House of Representatives State matching funding does not appear to be passed the American Health Care Act (AHCA) required for FIRSP. to replace the Affordable Care Act (ACA). States using Patient Stability Fund grants for high- Here is a partial summary of the Kaiser Family risk pools or reinsurance, or participating in the Foundation’s analysis of the AHCA’s provisions Federal Invisible Risk Sharing Program, can apply and its potential impacts. to waive the community rating factor for indi- vidual market participants who do not maintain Basic provisions of the AHCA continuous coverage. Instead, they can permit health status as a factor for rating variations. The ACA’s individual mandate and taxes would be immediately eliminated/repealed; under the FIRSP funds cannot be used to pay for any AHCA, a 30 percent surcharge would be assessed abortion or to assist in the purchase, in whole or to individuals who do not maintain continuous in part, of health benefit coverage that includes coverage, starting with special enrollment peri- small group markets. Such state waivers could alter coverage of abortion (except if the abortion is ods in 2018 and all other enrollments in 2019. the limits on essential health benefits, which in turn needed to save the life of the mother or if the pregnancy resulted from rape or incest). The ACA’s age rating limit of 3:1 would change to could affect the prohibition on lifetime and annual 5:1, unless states adopt different ratios, begin- dollar limits. ning in 2018. This provision limits the premiums A “Patient and State Stability Fund” would be Future of Medicaid assessed to older enrollees compared to the created for states to give financial help to high-risk The ACA’s state option to cover above 133 percent premiums of younger enrollees in the same plan. individuals, stabilize private insurance premiums, of the federal poverty level is eliminated after Dec. For 2018-19, premium tax credits would increase promote access to preventive services and provide 31, 2017. Federal payment for Medicaid expan- for young adults, but decrease for adults age 50 cost-sharing subsidies. The fund could also be used sion is limited to the 133 percent level to states and older with incomes above 150 percent of the for maternity coverage and newborn care, mental that adopted expansion by March 1, 2017, and is federal poverty level. health and substance use disorder services, and eliminated as of Jan. 1, 2020. other purposes. In states that do not successfully The ACA’s cost-sharing subsidies would then be apply for grants, funds would be used for a default Medicaid eligibility for children ages 6-19, up repealed as of 2020. Also that year, income-based to 138 percent of the federal poverty level, is reinsurance program, administered by the U.S. tax credits would be replaced with flat, age-based repealed as of Dec. 31, 2019. Centers for Medicare and Medicaid Services, that credits: $2,000 per person up to age 29; $2,500 would pay 75 percent of claims between $50,000 Medicaid funding is converted from guaranteed per person for ages 30-39; $3,000 per person for and $350,000 (starting in 2020, the CMS could payments made per person to a per capita cap ages 40-49; $3,500 per person for ages 50-59; and establish different reinsurance thresholds). starting in 2020; states could opt for a block grant $4,000 per person for age 60 and older. instead, for 10 years, starting in fiscal year 2020. As part of the Patient and State Stability Fund, a new “Federal Invisible Risk Sharing Program” — States could require work as a condition for Big decisions for states essentially a reinsurance program for patients who Medicaid coverage for enrollees who are not Starting in 2020, states could apply for waivers insurers think will be high-risk — is funded at $15 disabled, elderly or pregnant (although pregnant to redefine essential health benefits for health billion over nine years, plus any other unallocated women are exempted only through 60 days’ insurance coverage offered in the individual and funds under the Patient and State Stability Fund. post-partum) as of Oct. 1, 2017.

STATELINE MIDWEST MAY 2017 7 STATELINE PROFILE House Speaker Ron Ryckman After rare opportunity to serve alongside his father, lifelong Kansan now making his mark in top leadership position

by Laura Kliewer ([email protected])

ansas House Speaker Ron Ryckman never had to look far to find inspiration for getting Bio-sketch of Kansas Speaker Ron Ryckman Kinvolved in his community and, ultimately, running for political office.  Member of the House of Representatives since “My dad has been my role model my entire 2013 and elected House speaker in 2017; previously life, as far as someone who is dedicated to helping served as majority whip and as chair of the House others,” Speaker Ryckman says. In the small, rural town of Meade in southwest Appropriations Committee Kansas, his father, Ronald Ryckman, was well-known  Also serves as member of the Olathe City Council as a schoolteacher, coach and Sunday school teacher.  “He became a legislator later, after his retirement,” Lives in Olathe with wife, Kim, and three children Speaker Ryckman says. “I was kind of watching what  Business owner with a degree in business he was doing, and the opportunity arose for me to administration from MidAmerica Nazarene University be there.” He eventually found himself in the unique posi- tion of not only following in his father’s footsteps, but serving alongside him in the Kansas House of Representatives. His father left the Legislature at the “We try to remove emotions as much as we can and end of 2016, while he stepped into one of the state’s top leadership positions — speaker of the House. try to make our decisions based on data. We Though raised in southwest Kansas, Speaker encourage people not to make up their minds Ryckman has lived in the northeast part of the state ever since attending MidAmerica Nazarene until they get all the information from both sides University on a basketball scholarship. “I fell in love with the community, the schools and get information back from their district.” there and the family values — it is just a great place to live,” Ryckman says of Olathe, the fourth-largest city in Kansas. tried to make data-based decisions. And more How have your legislative priorities deepened He and his wife, Kim, are raising their three people had buy-in because more people were part Q: and expanded over your two-plus terms since children in Olathe, and in 2009, Ryckman deep- of the process; it was straightforward and honest. joining the Legislature? ened his community involvement by joining the I believe that was what a lot of my colleagues were I think the state is in a different place from a City Council. (He remains on the council today.) looking to when they elected me speaker. ... Being A: fiscal standpoint than it was four years ago. Three years later, he ran unopposed for a seat in speaker also provided the opportunity to talk to The commitment I have now to be fiscally respon- the Kansas House. a lot of folks and to find common ground, and to sible and balance the books is greater. I have more “Originally, it was to substantively spend more make our state a better place. It’s not only about responsibility for that to happen. It’s much more about time with my father,” he says about running for a problem-solving, but about creating opportunities being pragmatic. Finding coalitions and working with legislative seat, “and to help build a better Kansas for others. people to solve our fiscal issues is much heavier on my and future for my kids.” mind right now than it was four years ago. What followed was a quick rise in leadership, Is that how you would describe your legisla- including as chair of the House Appropriations Q: tive leadership style — straightforward and What have you enjoyed most about serving in Committee. After only two terms in office, honest? Q: the Kansas Legislature? Ryckman was elected House speaker. We are also very dedicated to process. It’s having the opportunity to solve prob- The influence of his father — particularly the A: If you trust the process, you trust the A: lems or create opportunities, and bringing collaborative style and the commitment to helping results. That doesn’t mean you always agree with people together to find political unifiers and build others — remains an important part of Speaker the results. We understand that everyone takes a voting bloc from there. Ryckman’s approach to leadership and legislating. away from family or business to be here, and they But his own experience as a father and as a spend a lot of time talking to their voters back What has been the biggest challenge, small-business owner (Ryckman is the CEO of a home. Everybody’s voice should be heard. That Q: especially now as speaker? local roofing company) helps inform his work in doesn’t mean we necessarily need to agree with Bringing people together to find consensus Topeka as well: “Lots of times it is just a matter of each other, but you need to be able to represent A: can be challenging. We try to remove sitting around a table and hearing each other, and your district — to be able to have the voices of emotions as much as we can and try to make our it can go a long way to finding your common goals.” Kansas heard and do it in safe environments where decisions based on data, and that is difficult to do. In a recent interview with CSG Midwest, you can have a civil discussion. We encourage people not to make up their minds Speaker Ryckman reflected on his legislative career until they get all the information from both sides and priorities, as well as his leadership style. Here So when you talk about being “dedicated to and get information back from their district. are excerpts. Q: the process,” are you referring to listening to constituents, and then coming back to Topeka What are your legislative priorities for this You became House speaker fairly soon after and talking to fellow legislators and making sure Q: year and beyond? Q: joining the Legislature. How do you explain everyone has a voice? To stabilize our budget so we have a sound that quick rise in leadership? That, and the way committees are set up, A: financial footing so we can fund core services I had had the opportunity to be appropria- A: making sure there is a balance of ideology and create a school finance formula that is data-driven A: tions chair, where we looked at data and and expertise. and reasonably calculated.

8 STATELINE MIDWEST MAY 2017 FIRST PERSON A FORUM FOR LEGISLATORS AND CONSTITUTIONAL OFFICERS A healthy collaboration Health care stakeholders’ input key as South Dakota addresses physician shortage by allowing expanded role for specialty nurses by South Dakota Sen. Deb Soholt ([email protected])

here is no dispute that health care is undergo- the bill through the legislative process. During eight ing an incredible transformation nationwide. State rules in Midwest on practice of months of preparatory work, supportive data were TInto the foreseeable future, states will be nurse practitioners crafted and major stakeholders were engaged. challenged to quickly innovate and remove un- Because this bill untied the license of the nurse necessary barriers to providing quality care at an practitioner or nurse midwife from that of the physician, affordable price. it was critical to reach out to formal physician groups This year, the South Dakota Legislature tackled as well as individual doctors. Ongoing communication one such barrier with the passage of SB 61, which was a key strategy, and the draft legislation changed will update, revise and repeal certain provisions considerably based on input before the bill was filed. relating to nurse practitioners and nurse midwives. Once introduced, SB 61 did face opposition. One Since 1979, our state’s certified nurse practitioners concern was that it would diminish quality of care. and midwives have been jointly licensed by South However, multiple studies do not support this claim. Dakota’s Board of Nursing and Board of Medicine. A 2010 report from the Institute of Medicine points That changes with enactment of SB 61, which to 50 years of evidence that primary care by certified modernizes our Nurse Practice Act by adopting Full practice: Nurse practitioners evaluate nurse practitioners and midwives is safe and effective. patients, handle diagnostic tests and manage national standards for the regulation of these treatments (including prescribing medications) Under the new law, too, these health professionals health professionals. under the exclusive licensure authority of the will not be practicing alone. The reality is that untying state board of nursing. By removing this requirement for joint licen- licenses with physicians does not make the role of nurse sure, nurse practitioners and midwives will no Reduced practice: Ability of nurse practitioners practitioners and midwives independent from the to engage in at least one element of their practice health care continuum. Within SB 61, the statutory re- longer need to maintain a career-long collaborative is reduced; state law requires a collaborative agreement with physicians in order to practice. agreement with an outside health discipline or quirement to be collaborative (including an operational As a result of this new law, South Dakota is now limits the setting or scope of one or more definition) was clearly defined. In addition, in states that elements of a nurse practitioner’s practice. aligned with its neighboring states that already al- already don’t mandate collaborative agreements, refer- low these certified health professionals to practice Restricted practice: Nurse practitioners are rals and physician-nurse partnerships remain the norm. restricted from engaging in at least one without contractual restrictions. element of thier practice; state requires In the end, the facts supported the merits of The new law gives our state’s Board of Nursing the supervision, delegation or team management SB 61: Nurse practitioners and midwives are vital sole authority to license and regulate certified nurse by an outside health discipline in order for the to the state’s health care workforce, and removing practitioners to provide patient care. practitioners and midwives. barriers to their licensure will help address our Source: American Association of Nurse Practitioners At one time, our state’s policy of requiring state’s primary-care workforce shortages while linked licensure and physician-nurse collaborative sustaining quality of care. agreements was a prudent one. We wanted to ensure by certified nurse practitioners; physician backup is Eighteen different organizations testified in that quality care continued with a new profession of available 120 miles away via the use of telemedicine. support of the bill, and though opposition was non-physician providers. strong, SB 61 ultimately passed the 105-member But over time, as roles and quality health out- Helping address mental health needs Legislature with only six “nay” votes. comes became firmly established, the collaborative Making statutory changes to the standing of ith 61 of the state’s 66 counties desig- one profession often can pit one group against agreement became merely “a piece of paper” that nated as a shortage area for mental health another, and this conflict leads to difficult choices interfered with the natural flow of practice. Problems professionals, our state needs a robust arose, such as having to close a clinic when a physician W among legislators. But with SB 61, the entire process strategy to educate and retain as much talent as did not have a current license — even though the remained respectful and was focused on the health possible. In other words, it’s going to take everyone certified nurse practitioners and midwives did — or needs of the state and the ability to recruit qualified we can get to meet the demands of mental health. having a collaborating physician hundreds of miles providers in all regions. Meeting this workforce challenge is not only away in a specialty that did not match the practice. The passage of SB 61 is an example of the critical to having a robust health care system, but it In South Dakota, one in five citizens lives in benefits of taking time to craft good policy and also will be a key part of implementing our recent designated primary-care shortage areas and 43 to build relationships along the way. It was my criminal justice reforms, which put a greater emphasis percent live in rural areas. By 2030, the state will need distinct honor to be prime sponsor of this win for on community-based rehabilitation and treatment. to increase its primary-care workforce by 27 percent the people of South Dakota! to meet demands; at the same time, 45 percent of our But our joint-licensure requirement proved to be a practicing physicians are older than 50. significant barrier in recruiting talented, experienced Sen. Deb Soholt, a Republican from Sioux Falls, was first Certified nurse practitioners and midwives are psychiatric faculty for South Dakota State University, elected to the South Dakota Senate in 2012 now employed in 57 of South Dakota’s 66 counties, where certified nurse practitioners are educated. and they are often the only primary-care provider Recently, after a nationwide search, a candidate who for miles around. For our state’s high percentage of accepted the opportunity ultimately declined upon Submissions welcome rural, isolated communities, there would literally be learning of joint licensure. She was unwilling to This page is designed to be a forum for legislators and no health care access without nurse practitioners: come to a state that tied her professional livelihood constitutional officers. The opinions expressed on this page For example, a small hospital in a community to another entity. of just over 1,500 people struggled with physician The health needs of South Dakota and the do not reflect those of The Council of State Governments or recruitment. Its innovative CEO then offered nurses licensure barrier for recruitment/retention of certified the Midwestern Legislative Conference. Responses to any an expenses-paid opportunity to go back to school nurse practitioners and midwives set the stage for FirstPerson article are welcome, as are pieces written on to become nurse practitioners if they would come SB 61. other topics. For more information, contact Tim Anderson back and work for three years. Now, 40 percent of A coalition that represented the “house of nursing” at 630.925.1922 or [email protected]. the hospital’s emergency-room needs are covered — education, regulation and practice — shepherded

STATELINE MIDWEST MAY 2017 9 CSG MIDWEST NEWS & EVENTS

Bipartisan mix of legislators chosen June 5 is deadline to lead interstate policy committees to register for MLC

Six committees will meet in July as part of Midwestern Legislative Conference Annual Meeting Annual Meeting

bipartisan, diverse group of legislators from The Midwestern Office of The Council of State he tradition of the nonpartisan, fam- ily-friendly Midwestern Legislative the region has been selected to lead the Governments provides staff support for these Conference Annual Meeting will continue Midwestern Legislative Conference’s policy groups. Here is a list of the CSG Midwest staff T A July 9-12 in a state capital recently ranked committees. Photos of the committee chairs and liaisons and their contact information: No. 1 on a Fortune list of the nation’s up-and- vice chairs can be found below. • Agriculture & Natural Resources — Carolyn coming downtowns. These six policy committees cover a broad range Orr, [email protected] The deadline to register for this year’s MLC of key issues in state government and help the MLC • Criminal Justice & Public Safety — Katelyn Annual Meeting in Des Moines, Iowa, is June 5. fulfill one of its core missions — to give legislators Tye, [email protected] The MLC is a nonpartisan group of all the chance to work with and learn from one another. • Economic Development — Laura Tomaka, legislators from 11 Iowa Sen. Janet Petersen, 2017 chair of the [email protected] Midwestern states MLC, chose the chairs and vice chairs. Appointing • Education — Tim Anderson, [email protected] and four Canadian authorities in the Midwest’s legislative chambers • Health & Human Services — Jon Davis, provinces. The choose up to three members to serve on the MLC [email protected] group’s Annual committees. Full committee rosters are available • Midwest-Canada Relations — Ilene Meeting, now in at csgmidwest.org. Grossman, [email protected] its 72nd year, is Each committee will meet on July 9 and host a the only event de- policy session on July 10 as part of the MLC Annual CSG also supports national policy commit- signed by and for Meeting in Des Moines. MLC committees also pass tees on education and workforce development, the Midwest’s legislators. policy resolutions, host legislative exchanges and energy and environment, budgets and economic Meeting registration can be completed at offer webinars on select topics. Committee members development, health, and transportation and www.csgmidwest.org. will develop and approve work plans for the bien- infrastructure. More information on these com- nium at this summer’s meeting. mittees is available at csg.org. MLC Annual Meeting highlights During various sessions at this year’s meet- Education Health & Human Services ing, attendees will: Committee chairs Vice chair Committee chairs Vice chair • explore how technology can improve state government; • examine the Midwest’s demographic and economic future; • learn the role for states in ensuring healthy birth outcomes; • review key trends in health care, public North Dakota Kansas Rep. Wisconsin Rep. Kansas Rep. Susan Illinois Rep. Nebraska Sen. safety, agriculture, education, economic Sen. Kyle Davison Melissa Rooker Eric Genrich Concannon Robyn Gabel Sue Crawford development and state budgets. This year’s featured speakers include: Economic Development Agriculture & Natural Resources • Isabel Wilkerson, author of the best-selling, Committee chairs Vice chair Committee chairs Vice chair award-winning “The Warmth of Other Suns”; • Kenneth M. Quinn, former U.S. ambas- sador and president of the World Food Prize Foundation; • Denise Kiernan, author of The New York Times best-seller “The Girls of Atomic City”; and • Harry Enten, senior political writer and Michigan Sen. Illinois Rep. South Dakota Minnesota Rep. Iowa Sen. Illinois Rep. Norine analyst for FiveThirtyEight. Ken Horn Elgie Sims Rep. Kevin Killer Paul Anderson Kevin Kinney Hammond Evening events, activities for guests Criminal Justice & Public Safety Midwest-Canada Relations Throughout the MLC Annual Meeting, too, attendees will have the chance to meet, learn Committee chairs Vice chairs Committee chairs from and collaborate with fellow state and provincial legislators from the Midwest. Evening events will be held at three premier Des Moines-area venues: the Opening Night Reception at the World Food Prize Hall of Laureates; Family Night at Illinois Sen. Ohio Rep. Indiana Sen. Ed Manitoba Ontario Speaker Michigan Sen. Living History Farms; and the State Dinner at Mattie Hunter Nathan Manning Charbonneau Minister Kelvin Dave Levac Jim Stamas the Iowa Capitol. Separate daytime activities will Goertzen be available for the adult guests and children of attendees.

The Council of State Governments was founded in 1933 as a national, nonpartisan organization to assist and advance state government. The headquarters office, in Lexington, Ky., is responsible for a variety of national programs and services, including research, reference publications, innovations transfer, suggested state legislation and interstate consulting services. The Midwestern Office supports several groups of state officials, including the Midwestern Legislative Conference, an association of all legislators in 11 states: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota and Wisconsin. The Canadian provinces of Alberta, Manitoba, Ontario and Saskatchewan are MLC affiliate members.

10 STATELINE MIDWEST MAY 2017 Midwest legislators chosen by peers to take part in summer leadership institute

hirty-nine legislators from 11 Midwestern states will be part of the 23rd class of the About the BILLD program Bowhay Institute for Legislative Leadership T  Development. Only leadership program designed exclusively A bipartisan committee of the region’s legisla- for newer state legislators from the Midwest (in CALENDAR tors met in early May to make the selections. their first four years of service) BILLD is the premier leadership program for UPCOMING MIDWESTERN LEGISLATIVE  A signature program of CSG Midwest’s newer legislators in the Midwest. This year, nearly CONFERENCE AND THE COUNCIL OF STATE Midwestern Legislative Conference 100 lawmakers applied for a BILLD fellowship. GOVERNMENTS EVENTS The institute will take place on Aug. 11-15 in  The program’s academic partner is the Minneapolis. It will include a mix of sessions on University of Minnesota’s Humphrey School of public policy, professional development and lead- 72ND ANNUAL MEETING OF Public Affairs ership training. Sessions are led by policy experts THE MIDWESTERN LEGISLATIVE CONFERENCE from the University of Minnesota’s Humphrey  There are more than 750 BILLD graduates, School of Public Affairs; legislative leaders from July 9-12, 2017 including current members of the U.S. Congress and Des Moines, Iowa the Midwest; and specialists in areas such as several of the Midwest’s top legislative leaders media training, consensus building and time Contact: Gail Meyer ([email protected]) management.  Contact Laura Tomaka at CSG Midwest for more 630.925.1922 The highly interactive curriculum also gives information: [email protected] or 630.925.1922 csgmidwest.org participants the chance to meet, learn from and work with lawmakers from across the region. 23RD ANNUAL Along with the state representatives and BOWHAY INSTITUTE FOR LEGISLATIVE senators selected by the Midwestern Legislative LEADERSHIP DEVELOPMENT (BILLD) Conference BILLD Steering Committee, a handful August 11-15, 2017 of provincial lawmakers will participate in this Minneapolis, Minnesota year’s institute. (The Canadian provinces are Nebraska Contact: Laura Tomaka ([email protected]) affiliate members of the MLC.) 630.925.1922 CSG Midwest provides staff support to the • Sen. Brett Lindstrom csgmidwest.org MLC and its BILLD program. The BILLD Steering • Sen. Tony Vargas Committee is led by three state legislators: Indiana • Sen. Anna Wishart CSG HENRY TOLL FELLOWSHIP Rep. Ed Clere and Ohio Sen. Cliff Hite, the commit- PROGRAM tee co-chairs; and Iowa Rep. Rob Taylor, vice chair. North Dakota August 25-30, 2017 Lexington, Kentucky Here is a list of this year’s BILLD Fellows. • Sen. Brad Bekkedahl Illinois • Rep. Brandy Pyle Contact: Kelley Arnold ([email protected]) • Rep. Shannon M. Roers Jones 800.800.1910 • Sen. Dale Fowler csg.org/LeadershipCenter/TollFellows.aspx • Rep. Sonya Harper Ohio • Rep. Anna Moeller • Rep. Theresa Gavarone GREAT LAKES LEGISLATIVE CAUCUS MEETING Indiana • Rep. Nathan Manning • Rep. Kent Smith September 22-23, 2017 Toronto, Ontario • Sen. Elizabeth Brown • Rep. Jack Jordan South Dakota Contact: Lisa Janairo ([email protected]) • Rep. Joe Taylor • Rep. Thomas Holmes 920.458.5910 greatlakeslegislators.org Iowa • Rep. Tim Reed • Rep. James Robert Smith • Sen. Jeff L. Edler MIDWEST INTERSTATE PASSENGER • Rep. Ashley Hinson Wisconsin RAIL COMMISSION MEETING • Rep. Charlie McConkey October 9-11, 2017 • Rep. David Bowen Wichita, Kansas Kansas • Rep. Rob Brooks • Rep. Mark Spreitzer Contact: Laura Kliewer ([email protected]) • Rep. Erin Davis • Rep. Nancy VanderMeer 630.935.1922 miprc.org • Rep. Linda Gallagher • Sen. Pat Pettey Alberta • Sen. Dinah Sykes CSG NATIONAL CONFERENCE • MLA Chris Nielsen December 14-16, 2017 Las Vegas, Nevada Michigan Manitoba • Rep. John Bizon Contact: Kelley Arnold ([email protected]) • MLA Nahanni Fontaine • Rep. Beth Griffin 859.244.8000 csg.org • Rep. Abdullah Hammoud Ontario Minnesota • To be determined • Rep. Jeff Backer Saskatchewan • Rep. Barb Haley • Rep. Dave Pinto • MLA Steven Bonk

STATELINE MIDWEST MAY 2017 11 CAPITOL roads andbridgesby 2024.Along withthe will begenerated annuallyfor thestate’s into law in April, anestimated $1.2billion Under Indiana’s HB1002,whichwas signed tation infrastructures. motor fuelsto invest more intheirtranspor braska In 2015,legislatures in cent pergallon. though annualincreases willbelimited to 1 Indiana’s gastaxwillbeindexed to inflation, gasoline. Insubsequent years, through 2024, ists paying atotal of28cents pergallonof 1;itwillresult onJuly inHoosierfect motor The increase 10-cent onmotor fuelstakes ef infrastructure.portation fees to generate more revenue for itstrans Midwest to raise thegastaxanduser-based Indiana 2015 to raise gastax Midwest state since Indiana becomesfifth terstate highways. state to authorize tolling onitsstretch ofin seek a federal waiver that would allow the of ed thestate Department Transportation to respectively. Indianalawmakers alsodirect to aseparate fee aswell —$50and$150, vehiclesof hybrid will be subject and electric state’s existing registration fee). The owners be imposedonallvehicles (on top ofthe gas taxincrease, anew$15annualfee will NONPROFIT ORGANIZATION and U.S. POSTAGE PAID hasbecome thelatest state inthe CAROL STREAM, IL Dakota South PERMIT NO. 1859

Stateline Iowa , raised taxes on Michigan ,

Midwest Ne CLIPS ------May 2017 - The Council of State Governments Wisconsin islooking to fullycover residential For the state’s entire population, Medicaid room.emergency increase copayments for multipletripsto the tween $0and$10,basedonincome) and wants to establishmonthly premiums (be job training program. Inaddition, Wisconsin less adults who are not working or not in a foralso calls a48-month timelimitfor child screening forenrollees. Medicaid Itswaiver would bethefirstU.S. state to mandate drug recipients Medicaid Some in drugscreening Medicaid first state to require Wisconsin wants to be treatment for substance abusedisorders. Midwestern Office According to abuse treatment program. be contingent on completing a substance- tests positive, would eligibility Medicaid drug test would berequired. For anyone who possible abuseofacontrolled substance, a tered questionnaire. Iftheanswers indicate would have to complete astate-adminis aconditionAs ofeligibility, individuals ance through theBadgerCare Plusprogram. less adultswhoare eligiblefor healthinsur This newrequirement would applyto child April. stration waiver submitted by thestate in if federal officials give the OK to a demon have to submitto drug screenings andtests 701 E. 22nd Street, Suite 110 Lombard, IL 60148-5095

Phone: 630.925.1922 The Washington Post Fax: 630.925.1930 Email: [email protected] csgmidwest.org Wisconsin

CHANGE SERVICE REQUESTED , Wisconsin will ------tissue notification requiring densebreast joinsstatesNebraska Minnesota laws, reporting density including Nebraska isnow among32states withbreast believes, to densebreast tissue. months ofamammogram due, herfamily resident who diedof breast cancer within18 law was anOmaha, named for Cheri Rauth, According to the methodswiththeirdoctor.and detection risk factors discuss so patients further can notice isbeinggiven to raise awareness and ing ofdensebreast tissueisnormal, andthat mography patients must be told that a find todifficult detect. Underthenewlaw, mam make tissuecan Such breast cancer more geneous orextremely densebreast tissue. to women ifamammogram reveals hetero The law requires that written notice begiven Unicameral Legislature by avote of48-0. lowing mammograms. Ithadpassedthestates’ women benotifiedofbreast fol tissuedensity 195, alsoknown as “Cheri’s Law,” requiring that Nebraska cer death amongwomen. Breast cancer isthesecond ofcan leading cause Breast-info.org. do notrequire reporting, according to Dense and Indiana Gov. Pete Ricketts inApril signedLB , have but public education efforts, North Dakota North Nebraska RadioNetwork and Ohio Michigan . Illinois , the ------,

activity results intheunintentionalactivity death of while drivingisconsidered “reckless.” Ifthis write, message” sendorviewanelectronic communicationheld electronic device to Under SF 444, an individual’s use of a “hand- bills to crack down onthesemotorists. This year, thestate’s lawmakers passedtwo ago,cade state statistics show. roads, nearlydoublethenumberfrom ade other devices 1,230crashes caused on In 2016,drivers by distracted theirphonesor Don’t text anddrive with stiffer penalties: Iowa sendsmessage strict young or strict “novice” drivers. phones; otherstates intheregion onlyre bans alldrivers from usinghand-heldcell Illinois offense.ting whiledrivingwas asecondary Dakota South Midwestern states ( Administration, Iowa hadbeenoneoffour According to theGovernors Highway Safety oftextingwhiledriving.they suspect police officers to pullover amotorist whom MoinesRegisterDes offense, texting whiledrivingaprimary A second billsignedinto law, SF234,makes years inprison. with aClass Cfelony, punishableby upto 10 another person,thedriver would becharged istheonlystate intheMidwest that are the others) where tex reports. This willallow Nebraska , Ohio Iowa and The The - - -