By Janus L. Norman CMA Senior Vice President, Centers for Government Relations and Political Operations In modern California politics, there is no more imposing figure than Governor Jerry Brown. Since his return to the Governor’s office, Brown and his administration have been able to develop and implement his policy agenda in a nearly flawless manner, overcoming every political obstacle in his pathway. Nowhere has Governor Brown’s dominance been more evident than in the crafting of the state budget. Prior to Governor Brown’s return and the passage of the majority-vote budget, the enactment of the state budget was a clash of political wills, a battle of ideals and priorities. The governor would present his vision in January. The Legislature would take months re-shaping and re-focusing the governor’s budget proposal. Tense negotiations would yield significant legislative changes in the budget and a handful of gubernatorial line-item vetoes. During his second tenure, Governor Brown has worked to deliver on-time budgets that do not significantly differ from his January proposals. This year, the state budget process was more critical than ever to the California Medical Association (CMA). The November 2016 election yielded another ballot measure victory for CMA and public health advocates across the Golden State with the passage of Proposition 56. CMA took on Big Tobacco and passed Prop. 56, which increased the tax on tobacco products by $2 per pack and stipulated that the new tobacco tax funds should increase access by improving provider payments. Despite being outspent, CMA and its partners in support of the measure got Prop. 56 passed overwhelmingly, providing an influx of new revenue to increase payments to Medi-Cal providers. Governor Brown, however, seeking to secure his legacy of fiscal prudence, sought to re-interpret the provisions of Prop. 56 to redirect the tobacco tax proceeds from Medi-Cal providers to the State General Fund. In his January budget proposal, Governor Brown didn’t include a rate increase for Medi-Cal providers. While there was an initial thought that the Governor was utilizing this proposal as a negotiation tactic to help shape the overarching discussion of the architecture for the state budget, it quickly became apparent that the Governor did not intend to ever support a rate increase for Medi-Cal providers. Thus, the battle began! The Governor’s intentions became more evident with the release of the Department of Finance’s May Revision. Just weeks before the constitutional deadline for the Legislature to pass the budget, the Governor doubled down on this earlier proposal and once again proposed no funding to support a Medi-Cal rate increase for providers. Restoring Prop. 56 funds was CMA’s top budget priority, and we engaged the Legislature through earned media, digital advertising, grassroots outreach and direct advocacy. CMA and its coalition partners, specifically the California Dental Association and Planned Parenthood, devoted the necessary resources to make sure that the Legislature followed the will of the voters and used the tobacco tax money to improve access to care in our state. CMA’s county medical societies and individual physician members made calls, wrote letters and conducted in-person legislative lobbying visits. Our legislative champions, led by Senator Richard Pan, M.D., and Assemblymembers Joaquin Arambula, M.D., and Jim Wood, D.D.S., pushed both the State Senate and Assembly to reject the Governor’s budget. The final budget, which Governor Brown signed, provides over $1 billion ($546 million in state funds, with a federal match) to improve provider payments, and nearly $750 million ($375 million in state funds, with a federal match) will be available to physicians. This victory was a collective effort of the entire CMA. A budget team was assembled, comprised of members of the Centers for Government Relations, Health Policy, Communications and Political Operations. Working in concert, this team successfully pushed the budget as CMA’s top legislative priority. Media coverage of the budget is always competitive, but the issue of Prop. 56 funding garnered a significant amount of attention, even among the sea of other budget fights, thanks to the persistence of the CMA communications team. Local physicians and county medical society executives were engaged in the fight, bringing the issue to the attention of their legislators at in-district meetings and to the Capitol on our Legislative Advocacy Day in April. The CMA Government Relations team, the face of the fight, came armed to each hearing and meeting with the expertise of the CMA Health Policy team. Although this fight will no doubt play out again in some future years and we will need to be vigilant to ensure continued funding, this year’s budget success seals the intent of the voters and will provide relief for California’s shamefully low Medi-Cal reimbursement rates. Amid the budget battle, the quotidian legislative work continued – as always. However, the routine was not without intensity. CMA this year pushed an aggressive legislative agenda through our package of sponsored bills, seeking to address a wide variety of our members’ issues. Two of our sponsored bills this year pertained to different aspects of the opioid crisis. SB 641 (Lara), which was put on hold for further discussion in the 2018 legislative session, is a supplement to Senator Lara’s SB 482 from last session, requiring use of the Controlled Substance Utilization Review and Evaluation System (CURES) for Schedule II-IV controlled substance prescriptions. Our bill would improve privacy protections in the mandated use of CURES. To deal with how opioids are prescribed, Assembly member Joaquin Arambula, M.D., introduced AB 1048, which allowed for partial fill of Schedule II prescriptions and removed the requirement for evaluating pain as the fifth vital sign. These changes will alleviate some of the pressure on physicians to prescribe and reduce the number of opioids given to patients. CMA also successfully pushed a clean-up bill for last year’s AB 2883, a workers’ compensation bill that inadvertently created hundreds of thousands of dollars of new, burdensome costs to physician practices. CMA’s bill—SB 189 (Bradford)—completely exempted physician practices from the workers’ compensation coverage requirement established by AB 2883, provided they have health insurance coverage. SB 189 will dramatically reduce the administrative cost of running a medical practice. Our highest profile legislative fight was over the Medical Board of California sunset review. This was the Legislature’s scheduled review of the medical board, during which it can make changes to the board’s policies and procedures and, crucially, extends the board past its “sunset” – that is, dissolution – date. What should have been an uneventful, perfunctory bill became a fight for CMA because of the inclusion of several provisions eroding physicians’ rights. We secured amendments to remove harmful provisions from the bill, including ones that would have reestablished a cost recovery program for the board, provided the board with new authority to issue cease practice orders and required certain physicians to notify their patients of their probation status. As ever with the two-year legislative cycle, the bulk of the first year’s work sets the stage for the second year’s. Discussions will resume in January over a host of issues, and CMA is well positioned in those conversations to protect the interests of physicians and their patients. Our strength this year builds our strength for next year.