As is often the case at the start of a fresh two-year term of the General Assembly, there isn’t much to report in the form of newly enacted legislation. In fact, an April 2 search of the legislature’s website for statutes enacted so far this year reveals “no records found.” Don’t be fooled, though. There is a lot going on, and much of it is health care-related. Following are some key early developments in what promises to be an interesting year, as Pennsylvania’s new Democrat governor, Tom Wolf, interacts with conservative Republican majorities in the state House and Senate.
2015-2016 State Budget
Pennsylvania’s annual budget process began with a proposed spending and revenue plan delivered by the governor in an address to a joint session of the General Assembly on March 3, and those expecting Gov. Wolf to offer an initiative very different from those of his Republican predecessor were not disappointed.
Overall, Wolf’s proposal would increase state spending by 2.7 percent (actually more than 8 percent if you include education spending), to be paid for with a variety of tax increases, including a raise in the state income tax from 3.07 percent to 3.7 percent, and a boost in the sales tax from 6 percent to 6.6 percent. The sales tax would also be expanded to include many services, though physician/patient office encounters are excluded.
Wolf’s proposal offers $8.5 million to expand the state’s loan forgiveness program for primary care physicians, more than doubling the current appropriation. He also recommends that the program be moved from the Department of Health to the Pennsylvania Higher Education Assistance Agency, commonly referred to as PHEAA.
Other significant health care items include a $2.5 million increase for behavioral health services and a $5 million increase to the Department of Drug and Alcohol Programs (DDAP) to address heroin and opioid addiction. PAMED works closely with DDAP on drug abuse issues.
The budget proposal also contains $3.8 million to reopen closed state health centers; $3 million for health care innovation, to fund a multi-payer payment and health delivery system transformation; and $100,000 for a new registry to compile health data from people living in Marcellus Shale drilling areas. PAMED supports the establishment of such a registry.
Importantly, the budget appropriates $2.147million to the Achieving Better Care by Monitoring all Prescriptions ABC-MAP program. That’s the official name for the newly enacted statewide controlled substance database. The database is supposed to be up and running by June 30 of this year, but that timetable has been jeopardized by a lack of funding in the current year state budget.
Additionally, the budget contains $2.7 million to continue the operation of the Pennsylvania Health Care Cost Containment Council (HC4), which was unfunded in the current year budget but continues to operate under a gubernatorial executive order.
While it is encouraging to see so many proposed health care-related spending increases, it must be noted that Pennsylvania’s state constitution requires revenues to match spending, and House and Senate Republican leaders have reacted negatively to Gov. Wolf’s recommended tax increases.
House and Senate budget hearings have now been completed, and work will soon begin on crafting the new revenue and spending plan, which is due by the end of the fiscal year on June 30.
Medical Marijuana Legislation on Center Stage
Legislation to legalize medical marijuana didn’t make it to the governor’s desk last year, dying in the state House after receiving Senate approval. However, Sen. Mike Folmer (R-Lebanon County) has reintroduced the measure, now Senate Bill 3, and it has already been the subject of House and Senate public hearings this year.
PAMED testified at the hearings, repeating our position that the FDA should relax marijuana’s status as a Schedule I drug to facilitate testing of a substance that seems to have some promise in treating children with epileptic seizure disorders, nausea in cancer patients, and other conditions. PAMED also believes the state should fund pilot studies that the Department of Health laid the groundwork for last year. However, until solid research results are in hand, the Society believes legalization would be premature.
Looking at the bill’s specific provisions, there are a number of reasons for concern. The bill’s scope is very broad, and goes well beyond the legalization of cannabidiol, the non-psychoactive component of marijuana that seems to help some children with seizure disorders.
SB 3 would also legalize THC, the psychoactive component of marijuana, to treat cancer, epilepsy and seizures, ALS, cachexia/wasting syndrome, Parkinson’s disease, traumatic brain injury and post-concussion syndrome, multiple sclerosis, Spinocerebellara Ataxia (SCA), post-traumatic stress disorder, severe fibromyalgia, and any other condition authorized by the Department of State.
This is despite a review in the February Journal of Developmental & Behavioral Pediatrics, the official journal of the Society for Developmental and Behavioral Pediatrics, stating that a growing body of evidence links cannabis to “long-term and potentially irreversible physical, neurocognitive, psychiatric, and psychosocial adverse outcomes.”
The bill would permit the medical use of marijuana edibles, presumably including THC-laced brownies and candy bars, raising concern over the risk of diversion and unintended harm. This has been a problem in states that have legalized medical marijuana, as evidenced by a 2011 study in Colorado that concluded that “diversion of medical marijuana is common among adolescents in substance treatment.”
The bill would authorize up to 65 growers and another 65 processors, far more than would seem necessary to provide marijuana-based products to a defined subset of patients with specifically enumerated conditions. Further, this creates more than 4,000 possible ways a specific medical marijuana product could get from grower to processor to dispenser, raising questions about product consistency.
The bill would permit physicians, CRNPs, podiatrists, nurse midwives and physician assistants to all “recommend” medical marijuana to patients, the antithesis of a go-slow, cautious approach warranted by legislation legalizing a Schedule I, non-FDA approved substance.
Yet another problem relates to physician liability. The bill provides that the Commonwealth can’t be held liable for any deleterious outcomes resulting from the medical use of cannabis by a registered patient, which makes sense given the paucity of scientific evidence supporting the safety and efficacy of medical marijuana. However, no similar protection is given to health care practitioners who will actually “recommend” non-FDA approved marijuana concoctions to their patients.
Despite these concerns, Senate approval is again expected early this year. House action on the legislation is less certain.
Naturopathic Licensure Bill Advances
House Bill 516, which would provide for the licensure of naturopaths and grant them a formal scope of practice, was recently approved by the House Professional Licensure Committee.
The bill would permit licensed naturopaths to independently prevent, diagnose, and treat human health conditions, injuries, and diseases. They would be able to order and perform physical and laboratory examinations, and utilize invasive routes of administration for their tests and treatments that include “oral, nasal, auricular, ocular, rectal, vaginal, transdermal, intradermal, subcutaneous and intramuscular.”
PAMED opposes the bill for several reasons. The level of credibility that state licensure establishes could be misleading to the average Pennsylvanian by implying that naturopathy is equivalent to mainstream medicine. “Naturopathic medicine” is defined in HB 516 as “a system of primary health care.” Patients may see unproven and possibly unsafe treatments by “naturopathic doctors” as a substitute for conventional medical care.
If there is doubt about whether the bill allows naturopaths to perform a particular test or treatment, the question would likely be resolved in their favor, as Section 102 (4) specifically calls for the act to be “liberally construed.”
Additionally, there is no requirement in HB 516 that naturopaths collaborate with or refer complicated medical cases to a physician.
The bill would also create logistical headaches for the state. Fewer than one hundred naturopaths would qualify for licensure under this bill, requiring the State Board of Medicine to establish and maintain the necessary infrastructure for a mere handful of people. The vast majority of Pennsylvania naturopaths would remain unlicensed after the bill is enacted, adding confusion and providing little, if any, protection to the general public.
The committee improved the bill slightly by deleting language that would have authorized licensed naturopaths to order diagnostic imaging studies, though that change is insufficient to warrant a change in PAMED’s opposition.