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ACNM Policy Update - 11/12/2014

1.  ACNM Analysis of Election Results – The State Picture
2.  ACNM Analysis of Election Results – The National Picture
3.  Supreme Court to Hear Another Challenge to ACA
4.  Annual March of Dimes Report on Preterm Birth Helpful for Midwifery Advocacy
5.  White House Invites Providers to Participate in Call with First Lady
6.  Don't Forget to Forward this Note to CNMs/CMs who are not ACNM Members

1.  ACNM Analysis of Election Results – The State Picture
While many eyes were on the Congressional election results, the states were busy deciding the fate of over 6,000 state legislative seats and over 30 gubernatorial races.  The importance of these midterm elections cannot be overstated for health policy since, as one commentator noted, the states are “where the action is” while Congress “is mired in gridlock.” Health policy issues, especially as they relate to the implementation of the Affordable Care Act (ACA), Medicaid expansion, and reproductive rights, are near the top of the policy agenda in numerous states.

The “red wave” that swept Congress is also evident at the state level, although at a somewhat less dramatic level as Republicans controlled 59 of 98 partisan legislative chambers prior to the election. Republicans now control 67 legislative chambers, five more than their previous record, and will hold supermajority status in at least 16 states. In 24 states the Republicans will now hold control of both chambers and the Governor’s office. Democrats have control of the legislature and executive office in only six states, by comparison.

Republicans were successful in the midterms even in states that have experienced a marked benefit from the ACA. County level analyses from across the country demonstrate that counties which experienced the biggest decrease in the number of uninsured individuals still polled heavily Republican. Numerous policy analysts have opined that this fact is not astonishing, as health reform appears to have faded as a priority issue for many voters. Moreover, even people who are generally supportive of the ACA note discontent with the Democrats who passed it.

The elections will impact a key aspect of the ACA – Medicaid expansion. Twenty-seven states have thus far expanded Medicaid as an optional provision of the ACA, but the election of Republican Governors in several of these states (IL, MD, and MA) may imperil existing expansion programs. The re-election of Republican Governors in Florida, Georgia, Wisconsin, Maine, and Kansas makes the prospect of Medicaid expansion in these states unlikely. However, even if Democratic candidates had prevailed in these states, there would still have been significant challenges pushing expansion through Republican-controlled legislatures. Maine is perhaps the one exception to this rule, as Gov. LePage has vetoed attempts to expand the program five times. 

Some Republican governors have expressed an interest in considering Medicaid expansion, however. Expansion advocates will be monitoring Utah, Wyoming, and Indiana as possible expansion sites in the near future.  There is also some hope that Medicaid expansion will become a less politically divisive issue, allowing states that were previously dismissive of the idea to potentially return to the table.

Abortion issues were on the ballot in several states. Colorado voters considered a personhood amendment for the third time since 2008. This year’s proposal would have included “unborn human beings” in the state’s criminal code. The measure has failed 65 to 35 percent. A similar initiative was considered in North Dakota, where it was proposed to add language recognizing the “inalienable right to life of every human being at any stage of development” to the state’s Constitution.  This measure also failed with over 60 percent of the electorate opposed.

Tennessee, by contrast, approved an amendment stating that, “Nothing in this Constitution secures or protects a right to abortion or requires the funding of an abortion,” with 53 percent of the electorate in favor.  New abortion restrictions in the state are likely once the legislature convenes.

Many ACNM members are likely anxious for consideration of how the midterm elections might affect full practice authority efforts. While Democratic legislators are traditionally more receptive to this type of legislation and it is possible that the red wave will result in some states opting not to introduce previously planned legislation, Republican controlled chambers do not necessarily spell doom for ACNM’s policy agenda. Many aspects of midwifery care, especially the cost-savings associated with midwifery’s excellent outcomes, are appealing to conservative lawmakers. Regardless of which party controls a particular chamber, the key to success often rests in how agendas are messaged. As always, affiliates are encouraged to customize talking points to specific audiences to maximize the opportunities for success.

Members with questions about state policy agendas should contact Cara Kinzelman, ACNM’s Manager of State Government Affairs, at [email protected].

2.  ACNM Analysis of Election Results – The National Picture

The 2014 election was significant for three specific reasons: 1) it dramatically changes the base of power in the Senate to Republican control with a significant majority, 2) it broadens the Republican base of control in the House, and 3) it restricts the ability of President Barack Obama to achieve much of his agenda during his final two years in office.  This is most certainly not what President Obama envisioned at a time when the economy is doing well and unemployment is at one of its lowest points in years. 

Many pundits like to say that midterm elections are about foreign affairs and presidential elections are about domestic policy.  Perhaps that trend is a partial reason for the very striking results of the 2014 election. 

A few weeks ago, it appeared the Republicans would have only a one-seat majority in the Senate, which would necessitate continued bipartisan cooperation with the Democrats in order to pass any significant legislation.  Instead, the Senate will see a larger than expected Republican majority (53 or 54 seats, depending on how the December 6 runoff in Louisiana goes) allowing the party to not only set the committee and floor agenda but also to craft legislation without widespread backing from Democratic colleagues.  Republicans still will not have a 60-vote filibuster proof majority, making it necessary to negotiate with Democrats willing to cross the line on issues.

Democrats in the House of Representatives lost 10 incumbents in comparison to just 2 Republican incumbents losses.  Republicans already had a firm hold on the House but this margin for Republicans has rarely been seen in U.S. history.  Watch for the Speaker of the House, John Boehner, to be more aggressive in his efforts to move legislation.

Several federal issues midwives care about, championed by ACNM, have been sponsored by Republican legislators in the House (a bill to establish maternity care shortage areas and a bill to allow midwives to certify admissions to acute care hospitals).  Those bills will seemingly have a better chance in this environment.  However, the champions on these and other issues in the Senate have been Democrats.  It will take time to identify Republican champions on these issues.  However, Midwives PAC has been supportive of candidates on both sides of the aisle – building relationships with legislators who support midwifery.  As a result of work by many ACNM members who have written to and visited with their legislators, our consistent presence on the Hill in the form of our Federal lobbyist and the Midwives-PAC’s careful strategy of donations to both Republican and Democrat offices, we feel confident that we will be able to garner support from both sides of the political aisle on several issues.

The Affordable Care Act (ACA) is clearly under attack from Republicans in Congress.  While votes will occur to repeal the law outright, of greater concern should be how Republicans will attempt to reform the law.  ACNM will be vigilant to ensure gains made for women’s health and the midwives who care for them are not rolled back as the law goes under the legislative knife.

Also of concern to ACNM will be the impact of the elections to the Medicaid programs, which are primary sources of funding for pregnancy related care in all states.  ACNM has sought increases to primary care payments for midwives and other primary care providers under Medicaid.  The election likely takes this issue off the table, as cuts are more likely in Medicaid that payment increases.   

Members with specific questions about this Update item should contact ACNM’s Federal Representative, Patrick Cooney at [email protected]

3.  Supreme Court to Hear Another Challenge to ACA

On November 7, the Supreme Court announced that it will hear another challenge to the Affordable Care Act (ACA). The last challenge to the ACA was upheld by only one vote.  This time the Court will consider whether the tax credits offered to individuals who qualify for subsidies are allowable due to a clause in the enacting legislation which states that people are eligible when they purchase insurance in a marketplace “established by the state.” The case calls into question subsidies granted to over 4 million people who purchased insurance through the 34 federally-run marketplaces. A ruling against the administration could mean that many individuals currently receiving subsidies would be faced with insurance premiums high enough that they would instead qualify for a hardship exemption and no longer be required to carry insurance.  Furthermore, the Administration has permitted health insurers to withdraw from the federally-run marketplaces if the Court revokes the subsidies.  Analysts predict this would mean that “only the sickest and most desperate” would attempt to purchase insurance on the exchanges, creating a ripple effect of increased insurance premiums due to escalating coverage costs and higher numbers of uninsured patients at hospitals.    
4. Annual March of Dimes Report on Preterm Birth Helpful for Midwifery Advocacy
This past week the March of Dimes released their annual report on premature birth in the United States. The state-specific summaries include state preterm birth rates and grade the states on prevention strategies like rates of uninsured women, late preterm birth, and maternal smoking. Affiliates could consider using this data juxtaposed against midwifery outcomes and associated cost savings as a compelling talking point for the benefits of increased access to midwifery care.
5. White House Invites Providers to Participate in Call with First Lady
The White House has issued an invitation to providers to participate in a conference call with First Lady Michelle Obama to discuss the upcoming open enrollment period for the health insurance marketplaces. 
Call Details
- Date: Friday, November 14th 
- Time: 1:25 PM ET, please join 5-7 minutes early to avoid connection delays
- RSVP: To receive the dial-in information, please register for the call by clicking here
6.  Don't Forget to Forward this Note to CNMs/CMs who are not ACNM Members
As usual, if you know any CNMs/CMs who are not currently ACNM members, please forward this Policy Update to them.  We want to be sure they know what the association is doing on their behalf and the kinds of activities that their membership would support.

Should you have questions about state issues, please contact Cara Kinzelman, ACNM's Manager of State Government Affairs at [email protected] or 240-485-1841.  

If you have questions regarding federal issues, please contact Jesse Bushman, ACNM’s Director of Advocacy and Government Affairs at [email protected] or 240-485-1843. 

Not an ACNM member?  You can access all of the member benefits, including receipt of every ACNM Policy Update, by joining today.  

Want to take action or get involved?  Contact ACNM's Government Affairs Committee.

Don't have the time or energy to get involved, but still want to contribute?  Support the Midwives-PAC.


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