State Governors Elect Not to Implement Parts of PPACA

After the United States Supreme Court’s ruling last week that states cannot be forced to expand their Medicaid programs to receive federal funding, states are given the tough decision to make whether they will indeed expand their Medicaid rolls as suggested by the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148).

Thus far, five states have made it clear that as a result of last week’s decision, they do not plan to expand their Medicaid programs: Florida, South Carolina, Louisiana, Mississippi and Wisconsin.

All of those five states, which have Republican governors, participated in the lawsuit against the bill, which was the subject of last week’s ruling. In addition, six states have publicly raised doubt as to whether they will participate: Iowa, Missouri, Nebraska, Nevada, New Jersey and Texas. Currently, only ten states have affirmatively pledged to participate in Medicaid expansion, which leaves nearly two-thirds of the states in question.

Wisconsin Governor, Scott Walker issued a statement on the same day the Supreme Court released their decision on PPACA, indicating, “Wisconsin will not take any action to implement ObamaCare.” (Obama Care is a casual term commonly used to refer to PPACA and its provisions.) Walker emphasized his concerns that the bill would cost his state’s tax payers to “pay more money for less healthcare” and that both quality of and access to care would be reduced under the bill. He expressed his hope that this year’s elections would ultimately result in the repeal of the bill at a federal level.

Governor Bobby Jindall of Louisiana announced that his state will not be expanding its Medicaid program in response to PPACA; nor will it be setting up private health insurance exchanges called for by the bill. Under the provisions of PPACA, if Louisiana or any other state fails to establish a fully operable exchange by January 1, 2014, the federal government will implement an exchange for that state. Jindall agreed that reform of the health care system is necessary, but that an “expensive, unsustainable entitlement program is not the solution to our problems.”

In Florida, Governor Rick Scott similarly announced that his state will neither set up exchanges nor expand its Medicaid rolls to comply with PPACA. Approximately 20 percent of Florida residents are uninsured, however, Scott pointed out that it would cost Florida taxpayers $1.9 billion to add those residents to the Medicaid program. He raised concern over the rapidly increasing Medicaid program in the state, which he said is growing “three and a half times as fast as Florida’s general revenue.”

South Carolina Governor Nikki Haley declared that her state will opt out of expanding its Medicaid program and that block grants, which offer flexibility to states as to how they will use the money, offer the best solution to state-specific problems. She referred to PPACA’s changes as a “broken system that further ties our hands.”

Lt. Governor Tate Reeves of Mississippi “is not inclined to drastically expand Medicaid” as called for by PPACA. He explained that such an expansion, which would add nearly 400,000 residents to the program, would cost the state nearly $1.7 billion over ten years. He maintained that “(t)rue health care reform should look at reducing costs for services not increasing the burden on taxpayers.”

Optometrists vs. Ophthalmologists in Pennsylvania: Who Can Do What?

A new piece of legislation in Pennsylvania is causing friction between optometrists and ophthalmologists by attempting to limit the scope of practice for optometrists. Their roles often confused, optometrists are referred to as “doctors of optometry,” despite the fact that they do not possess a doctor of medicine degree, but four-year degrees. Optometrists commonly perform vision examinations and write prescriptions for contacts and eyeglasses. On the other hand, ophthalmologists are eye surgeons who possess a medical degree and have completed a one year internship and a three year residency. The current law on the Pennsylvania books was enacted over 30 years ago and states that the practice of optometry shall not include surgery, use of a laser, or injections to treat ocular disease.

However, as medicine has evolved, some other states have begun to include more treatments within the definition of optometry. Most recently, Kentucky has amended laws to permit optometrists to perform laser eye procedures and cosmetic work around the eyes. Supporters of the legislation argued that such expansion was essential to ensuring the availability of treatment for patients in the state where there are four optometrists for every single ophthalmologist. Other states, such as Nebraska, Texas, and South Carolina, are evaluating similar legislation.

The Pennsylvania legislation, House Bill 838, is the opposite of the Kentucky bill as it seeks to limit “palliative, therapeutic, rehabilitative [or] cosmetic [procedures] for conditions or disease processes involving the eye…utilizing lasers, cautery, ionizing or nonionizing radiation, scalpels, probes, needles or other instruments in which the human eye…is cut, drained, penetrated” to the practice of ophthalmologists only.

 Advocates of the bill contend that a medical school education and subsequent internship is essential to delivering safe eye surgery to patients and handling any systemic complications that may arise. One supporting ophthalmologist, Kenneth Cheng, stated that while “there are eye procedures that are easier and faster than they were years ago, citizens of Pennsylvania expect that anyone performing surgery on the eye, including laser surgery, has gone to medical school.”

Opponents of the bill, which include the American Optometric Society (AOS) and the Pennsylvania Optometric Association (POA), see the legislation as a “direct frontal attack” on the practice of optometry. The POA has declared the bill “unnecessary and redundant” and claims that the current law in place already bars optometrists from performing surgery. What some see as a defense against the expansion of the practice of optometry others see as a restriction that may technically bar more than just surgery. According to the AOS, the bill specifically lists the  technologies that may be used in the practice of optometry and requires legislative approval for the use of any future technologies or changes in care standards. The Pennsylvania Academy of Ophthalmology counters that the bill simply removes ambiguity from the original statute and does not narrow the current scope of the practice of optometry.

The bill was widely approved by the Pennsylvania House last summer and is awaiting action by the state Senate’s Professional Licensure Committee.