On Nov. 5, voters in a number of states will do much more than decide who will occupy the White House next year. They will decide a number of issues that directly affect how providers and insurers do business.
Topping the list are several referendums in California.
Two of the items are so-called "patient protection" initiatives: Proposition 214, sponsored by the Service Employees International Union, and Proposition 216, sponsored by the California Nurses Association and a Ralph Nader-backed consumer group.
Both initiatives would prohibit the use of "gag clauses" by managed-care plans and impose staffing requirements on healthcare facilities. Proposition 216 also would impose taxes on hospitals that reduce their work forces, and it would create a new public corporation to act as a patient advocate.
Proponents say a study shows that Proposition 216 would save Californians up to $7 billion over five years-money that could be spent on uncompensated care. Opponents, including the California Chamber of Commerce and the California Healthcare Association, point to a Legislative Analyst Office report claiming the initiatives would impose "tens of millions of dollars" in new healthcare costs. The initiatives trail in the polls.
Another measure, Proposition 215, would advance the medicinal use of marijuana. It is sponsored by Californians for Compassionate Use, a group including physicians and nurses. It would "exempt from criminal laws patients and defined caregivers who possess or cultivate marijuana for medical treatment recommended by a physician." Physicians who recommend the use of marijuana wouldn't be prosecuted. The California Medical Association and law enforcement agencies oppose the measure. It's supported by several of the state's newspapers and labor unions.
Several other states also have managed-care-related ballot initiatives.
In Oregon, Measure 35 would ban capitation as a form of provider payment. Providers would be required to comply by Dec. 31, 1997, or face suspension of their license. The state's managed-care industry as well as the state medical society oppose the measure.
Measure 39, meanwhile, would require all health insurers and workers' compensation plans to allow patients to choose alternative providers such as chiropractors and acupuncturists. A consortium of alternative providers supports the measure; a consortium of traditional providers, businesses and insurers opposes the measure.
Measure 44 would increase the cigarette tax by 30 cents a pack to fund the Oregon Health Plan-the state's Medi-caid expansion program-and programs aimed at reducing tobacco use.
Access also is an issue in Arizona, where a state ballot initiative would extend healthcare benefits to previously uninsured families. Proposition 203, dubbed the "Healthy Arizona" initiative, would allow a family of four with income of $15,000 a year or less to have access to state-covered healthcare benefits. The current cutoff is $6,000. The same initiative also would siphon $17 million in revenues from the state's lottery to boost funding of community healthcare programs dealing with women and children, teen pregnancy and children's nutrition.
Public support for Healthy Arizona is unclear. It was recently reinstated on the ballot by the Arizona Supreme Court. A lower court removed it because about 8,000 signatures on a petition used to put the measure on the ballot were invalid because the voters had changed their address without re-registering to vote.
Meanwhile, voters in Colorado and Nevada will decide which providers will or will not pay taxes.
In Colorado, a proposed amendment to the state constitution would eliminate the property-tax exemptions of select not-for-profit organizations, including hospitals and churches. Property-tax exemptions would continue for schools, colleges and universities, correctional facilities, orphanages, and housing for low-income elderly, disabled, homeless or abused persons.
The amendment would affect roughly 7,500 properties throughout the state with a taxable value of more than $800 million. At least $70 million in property taxes would be collected. But the amendment calls for property-tax rates to be reduced proportionately to prevent any gain in property-tax revenue. The Colorado Hospital Association opposes the amendment, arguing that it will raise hospitals' operating costs and reduce available hospital resources.
In Nevada, Proposition 13 would exempt orthotic appliances, ambulatory casts and similar supports along with splints and bandages from sales taxes if they are prescribed by a licensed healthcare provider.
In Missouri, a ballot question on wages would affect all providers. A proposed increase in the state minimum wage to $6.25 an hour, with 15-cent increases to follow each year, has hospitals and nursing homes in a fever. They argue that if Proposition A passes, it will boost labor costs unreasonably for hourly workers. The measure is sponsored by the Teamsters and ACORN, an activist group, who say the federal minimum wage doesn't raise low-income workers out of poverty.
Finally, the business activities of public hospitals is the subject of ballot initiatives in at least three states.
A proposed amendment to the Idaho Constitution would allow the state's 28 county, district and joint city/county hospitals for the first time to participate in business relationships like their private hospital counterparts.
Specifically, the measure would allow Idaho public hospitals to engage in shared services and other joint or cooperative ventures, to enter joint ventures and partnerships to finance facilities and projects, and to participate in other sharing arrangements to provide healthcare services.
The amendment would remove an obstacle for public hospitals to engage in such activities by exempting them from a provision of the state constitution that bars state and local government-controlled organizations from lending money to or sharing financial risk with private corporations. The Idaho Hospital Association supports the amendment, which the state Legislature passed and placed on the ballot.
Voters in South Carolina and Tennessee will decide whether to give up control of their public hospitals to one or more regional private not-for-profit hospital systems.
The 362,000 residents of Greenville County, S.C., will vote on whether to allow Greenville Hospital System to create a merger-like partnership with two other regional hospital systems in South Carolina.
The other systems are Spartanburg (S.C.) Regional Healthcare System and Anderson (S.C.) Area Medical Center.
The controversial partnership would give the three systems a virtual monopoly over acute-care hospital services in the northwestern section of South Carolina known as upstate. A coalition of smaller competing hospitals, some area businesses and some state legislators opposes the deal, which also is being investigated by the U.S. Justice Department for possible antitrust violations (July 29, p. 2).
The referendum, placed on the November ballot by a resolution from the Greenville County Council, asks voters whether they "approve of" the seven-hospital public system transferring its assets, programs and facilities to the new partnership. But whether the referendum is binding on the hospital system is open to debate and is the subject of at least one local lawsuit.
Meanwhile, the 25,000 residents of Cookeville, Tenn., will decide whether to lease the city-owned Cookeville General Hospital to Fort Sanders Health System of Knoxville, Tenn. The City Council supports the lease, which was tentatively signed in July, while the hospital administration and board oppose the lease. In fact, last month the board signed a tentative affiliation agreement with two other hospitals.
The ballot asks Cookeville residents to vote for or against a city ordinance, passed in July, that allows the city to lease the hospital to Fort Sanders in a deal worth more than $150 million.