State Update

State legislatures around the country are continuing their focus on regulating and taxing tobacco products, such as cigarettes, cigars, and chewing tobacco. However, over the last few years, there has been increased attention given to e-cigarettes. Electronic cigarettes, also known as e-cigarettes, are battery-operated products designed to deliver nicotine, flavor and other chemicals. E-cigarettes turn nicotine and other chemicals into a vapor that is inhaled by the user. These products are often made to resemble cigarettes, cigars, and pipes; however, they may also look like everyday items, such as pens and USB memory sticks, for people who wish to use the product without others noticing. California S.B. 648 has been introduced by Senate Majority Leader Ellen M. Corbett (D-CA). The bill extends the restrictions and prohibitions against the smoking of tobacco products to include restrictions or prohibitions against e-cigarettes in various places, including, but not limited to, places of employment, school campuses, public buildings, day care facilities, retail food facilities and health facilities. The bill also prohibits, to the extent not preempted by federal law, a person from selling or otherwise furnishing an e-cigarette to a person less than 18 years of age. The bill was scheduled to be heard in the Assembly Committee on Governmental Organization on August 7 and August 14, however, the bill sponsor pulled the bill down from committee consideration due to a lack of votes for passage. According to the committee clerk, the bill will be deemed a two-year bill and will be brought back for consideration in January or February 2014. Illinois On August 15, Gov. Pat Quinn (D-IL) approved S.B. 1756. The new law prohibits the distribution of alternative nicotine products to persons under the age of 18, and defines alternative nicotine products to include products such as e-cigarettes.   Massachusetts Rep. Jeffrey Sánchez (D-MA) has introduced H. 3639. The bill would restrict the sale of any tobacco or nicotine delivery product to minors and prohibit use of the products on public school grounds. Additionally, the bill would apply existing state public and workplace smoking bans to electronic cigarette use and restrict the distribution of product samples. H. 3639 has been referred to the Joint Committee on Public Health for further consideration. North Carolina Gov. Pat McCrory (R-NC) signed S. 530 into law on June 19. The new law classifies e-cigarettes as tobacco products. This revised definition of tobacco products allows North Carolina to regulate e-cigarettes. The law also prohibits the sale of tobacco products, tobacco-derived products and vapor products to minors, and requires retail distributers to display a sign indicating that the sale of these products to minors is a violation of North Carolina law. Additionally, Alabama, Arkansas, Colorado, Mississippi, and South Carolina have passed legislation regulating e-cigarettes. The federal government is also interested in e-cigarettes. On September 6, the Centers for Disease Control and Prevention (CDC) released new data related to e-cigarettes. According to the CDC, e-cigarette experimentation and recent use doubled among U.S. middle and high school students during 2011–2012, resulting in an estimated 1.78 million students having ever used e-cigarettes as of 2012. Moreover, in 2012, an estimated 160,000 students who reported ever using e-cigarettes had never used conventional cigarettes.   On September 5, U.S. Senators Dick Durbin (D-IL), Richard Blumenthal (D-CT), Tom Harkin (D-IA), Tom Carper (D-DE), and Ed Markey (D-MA) warned against the dangers of electronic cigarettes after the CDC released data showing that use of these products has more than doubled among middle and high school students since the 2011-2012 school year. According to the CDC, e-cigarettes that are not marketed for therapeutic purposes are currently unregulated by the Food and Drug Administration (FDA). However, according to the FDA, the agency intends to issue proposed regulations.

Washington The Dental Quality Assurance Commission (commission) has issued an interpretive statement about the Dentist Scope of Practice – Use of Botulinum Toxin Injections/Dermal Fillers. The interpretive statement was approved by the commission on July 26, 2013, and filed by the Office of the Code Reviser on August 20, 2013, as WSR 13-17-090. The use of botulinum toxin injections or dermal fillers in the soft tissues throughout the face can be within the scope of practice of a dentist licensed under chapter 18.32.020 RCW when: Used to treat functional or esthetic dental conditions and their direct esthetic consequences; and the treating dentist has appropriate, verifiable training and experience. According to the commission, the use of botulinum toxin injections or dermal fillers outside the treatment of dental-related conditions for purely cosmetic purposes is not within the scope of practice of dentists who are not specially trained as oral and maxillofacial surgeons (RCW 18.32.020).

During the 2007–08 Regular Legislative Session, the Minnesota Legislature passed, and the governor signed, H.F. 1078–an omnibus health and human services finance bill. Under the law, all hospitals and health care providers must have in place an interoperable electronic health records system within their hospital system or clinical practice setting by January 1, 2015. In 2008, the Minnesota Department of Health (MDH) released a statewide implementation plan to meet the 2015 interoperable electronic health record mandate. Recently, the MDH released a guidance document further detailing which health care settings and providers would be impacted by the mandate. According to the guidance document, dental practices–including general practice, oral surgery, and orthodontics–will be impacted by the mandate. In addition, MDH has stated that it interprets the law to include any health care provider who provides a service that could be reimbursed by Medical Assistance or MinnesotaCare, whether or not the provider accepts these patients or accepts payment for the service. To learn more about the 2015 interoperable electronic health record mandate, click here.

On July 11, the National Governors Association (NGA) announced that it had formed a State Health Policy Advisory Board (board), in an ongoing effort to provide governors and state policymakers with assistance and technical support on health care issues. According to the NGA, “[i]n times of complex navigation of health care implementation, the advisory board was created to bring both a broader and deeper perspective to the existing health care assistance NGA provides to governors.” Members of the board will serve two-year terms and include the following: Joe Anderson, former CEO, Schaller-Anderson John Breaux, former U.S. senator from Louisiana Jim Douglas, former governor of Vermont Patricia Gabow, former CEO, Denver Health George Halvorson, chairman, Kaiser Permanente Carmen Odom, president, Milbank Memorial Fund Peggy O’Kane, president, National Committee for Quality Assurance Mark Smith, M.D., CEO, California Healthcare Foundation  Olympia Snowe, former U.S. senator from Maine Stephen Somers, president, Center for Health Care Strategies

On June 28, the U.S. Department of Agriculture issued an interim final rule, setting new standards for foods and beverages that can be sold in schools. The interim final rule requires schools to improve the nutritional quality of foods offered for sale to students outside of the federal school lunch and breakfast programs. The new standards also apply to foods sold à la carte in school stores, snack bars, or vending machines. The rule sets stricter standards for the amount of fat, sodium, and sugar that can be contained in snack foods that are sold to students. The majority of the provisions in the rule must be implemented beginning July 1, 2014. However, the interim final rule does provide a special exemption for items that are sold during certain school-sponsored fundraisers.   The new rule outlines eligible beverages for elementary, middle, and high school students. Overall, allowable beverages for students are limited to: Plain water (carbonated or uncarbonated); Lowfat milk (unflavored) and nonfat milk (including flavored), and nutritionally equivalent milk alternatives (as permitted by the school meal requirements); and Full-strength fruit or vegetable juices and full-strength fruit and vegetable juice that is diluted with water or carbonated water. For elementary students, all beverages must be no more than 8 ounces, with the exception of water, which is unlimited. For middle school students, all beverages must be no more than 12 ounces, with the same exception for water. Additionally, for elementary and middle schools, foods and beverages must be caffeine-free, with the exception of naturally occurring trace amounts. For high school students, milk and milk-equivalent alternatives, as well as fruit or vegetable juice, must be no more than 12 ounces. Also allowed in high schools are calorie-free, flavored and/or carbonated water, and other calorie-free beverages that comply with the U.S. Food and Drug Administration requirement of less than 5 calories per 8 ounce serving (or less than, or equal to, 10 calories per 20 fluid ounces), in no more than 20 ounce servings. Additionally, beverages containing caffeine are permitted in high schools. The new rule also sets standards for total sugar content in certain foods and snack items. Under the rule, total sugar must be no more than 35% by weight. Exemptions to the sugar standard are provided for dried whole fruits or vegetables; dried whole fruit or vegetable pieces; dehydrated fruits or vegetables with no added nutritive sweeteners; and dried fruits with nutritive sweeteners that are required for processing and/or palatability purposes. To view a chart summarizing all the food and beverage changes, click here. To view a summary only of the new beverage standards, click here.

Arizona During a special session called by Gov. Jan Brewer (R-AZ), the Arizona Legislature passed H.B. 2010 to expand Medicaid under the Affordable Care Act. Gov. Brewer signed the bill on June 17. Toward the end of the regular legislative session, Gov. Brewer began vetoing legislation, making good on a promise to refuse to sign additional measures into law until the Arizona Legislature passed a 2014 budget and a Medicaid expansion bill. However, an opposition group, led by former state Sens. Frank Antenori (R-AZ) and Ron Gould (R-AZ), has until September 11 to gather 86,405 valid signatures to put the measure to a vote. If they succeed, Medicaid expansion will be blocked until the November 2014 general election. Colorado Gov. John Hickenlooper (D-CO) signed into law H.B. 1320, creating a new class of merit scholarship for Colorado residents who achieve certain criteria, such as a high grade point average or a high class rank. The bill allows state-supported institutions of higher education that enroll Colorado Scholars to count each of them as two in-state students when calculating the ratio of in-state to out-of-state students, thus effectively giving institutions a way to enroll a larger proportion of out-of-state students without violating the statutorily mandated cap on non-resident students. Under existing law, 55% of incoming freshmen enrolling at state institutions of higher education, and not less than two-thirds of total student enrollment, must be resident students. Some argue that the law allows Colorado colleges and universities to generate more in tuition revenue at a time when state support for higher education has decreased. Maine LD 1230, sponsored by Speaker of the House Mark Eves (D-MA) and co-sponsored by more than 40 members of the House of Representatives and the Senate, would have established the role of dental hygiene therapist, but failed to pass the Senate. On June 18, the House adopted the bill with amendments by a vote of 95-45; however, the Senate rejected the bill 21-14 the following day. Texas Gov. Rick Perry (R-TX) signed into law S.B. 8 on June 14. The law requires the Executive Commissioner of the Health and Human Services Commission (HHSC or commission) to establish a data analysis unit within the commission to improve contract management, detect data trends, and identify anomalies in the provision of Medicaid and Children's Health Insurance Program (CHIP) services and contracts. The law establishes rules prohibiting certain unsolicited personal contact through direct marketing by providers participating in Medicaid or CHIP. The law authorizes HHSC to review and provide authorization of provider-proposed marketing activities and adopt rules that exempt certain marketing activities from the prohibition. The law also requires HHSC to enter into a memorandum of understanding with the Texas Department of Motor Vehicles and the Texas Department of Public Safety to obtain motor vehicle and driver's license information of a provider of medical transportation services. Additionally, under the new law, HHSC is required to review the prior authorization and utilization review processes within the fee for service delivery model and to monitor Medicaid managed care organizations to ensure that the organizations are using prior authorization and utilization review processes.

On May 17, the Supreme Court of Iowa ruled in favor of the Iowa Dental Association in the case of Iowa Dental Association v. Iowa Insurance Division and Iowa Insurance Commissioner, reversing the decision of the Iowa District Court for Polk County.