N.D. Legislature: Med school legislation a thorny issue

If circumstances were different, North Dakota's public health advocates would have loved to support a bill going before the Legislature that would fund more health care workers for the state.

Instead, they feel like they have to "choose between two children," former state Attorney General Heidi Heitkamp said Monday.

Choosing to train more health workers would mean dramatically less funding for the state's tobacco prevention and control program, a program Heitkamp and other public health advocates say has reduced tobacco use statewide and was approved by voters in 2008.

But choosing to keep anti-tobacco programs as they are would dramatically diminish the chances of getting funding for health worker training in this biennium.

House Bill 1353 would take tobacco settlement money used for anti-tobacco programs to pay for an expansion of UND's School of Medicine and Health Sciences. Gov. Jack Dalrymple declined to put the expansion on his budget and it's the only bill so far that's taking up the cause.

Rep. Bob Skarphol, R-Tioga, its author, said he feels the money would be better spent training more health workers than helping smokers quit. "They're addressing the needs of 18 percent of the state population. My proposal would support 100 percent."

Centers for Disease Control and Prevention data shows that, in 2009, 18.6 percent of adults statewide smoked. In 2004, 19.9 percent of adult North Dakotans smoke.

Because the bill would override a referendum, a two-thirds supermajority vote is needed. Skarphol, who heads the Education and Environment Division of the House Appropriations Committee, said he's confident he has the votes needed.

Co-sponsors of the bill include committee chairpersons such as Rep. Robin Weisz, R-Hurdsfield, chairman of the House Human Services Committee; Sen. Judy Lee, R-West Fargo, chairwoman of the Senate Human Services Committee; and Sen. Ray Holmberg, R-Grand Forks, chairman of the Senate Appropriations Committee.

HB 1353 is scheduled to go before the House Education Committee on Monday.

Lots of money

At stake is an estimated $104 million altogether between now and 2017.

The majority of tobacco settlement funds, a projected $46.1 million in the upcoming biennium, will continue to pay out indefinitely -- pretty much as long as tobacco is sold, according to Heitkamp, who was among the several state attorneys general who sued the tobacco industry.

But most of that goes toward schools and water projects, with 10 percent going to public health. Most of that public health money now goes to the anti-tobacco program.

The main source of anti-tobacco funding, however, is money that the tobacco industry is paying out as, essentially, attorney fees racked up by the state attorneys general. The payout started in 2008 and will continue until 2017. In the upcoming biennium, payout is expected to total $27.6 million.

Momentum

The state's anti-tobacco program, run by the Center for Tobacco Prevention and Control Policy, now uses roughly half the money it gets every biennium. According to Jeanne Prom, the center's executive director, the program will be able to continue into 2027 even though payout ends in 2017.

What it pays for is a series of programs recommended by the CDC. Half the money goes to prevention, including many grants to local agencies, such as Grand Forks Public Health. Among other things, this helps pay for efforts to ban smoking in public places. A quarter of the money goes to classes to help smokers quit. About an eighth pays for ads and other public relations efforts to encourage quitting and discourage nonsmokers from starting. The rest pays for data gathering and administration.

Altogether, it's a $9.3 million a year program, of which about $6.4 million comes from the fund that is being threatened by HB 1353.

Heitkamp and Prom point to evidence of the success ranging from the drop in state cigarette tax revenue -- it dropped from $19.8 million in fiscal year 2007 to $18.5 million in fiscal year 2010 -- to the number of people using the state Quitline. The number of those going into nicotine replacement therapy rose from 562 in fiscal year 2008 to 3,374 in fiscal year 2010.

Heitkamp said she fears the momentum would be lost because the tobacco industry spends a lot of money advertising its wares. "If you stop doing what you're doing you're going to see progress reverse." A breast cancer survivor, she compared it to women being encouraged to get mammograms after a certain age. Just because breast cancer rates have fallen doesn't mean you can say it's time to stop doing mammograms, she said.

Besides the human toll, there's a cost to government as well, according to Prom, who cited CDC data that estimates that $47 million in Medicaid costs borne by the state and federal government is attributable to tobacco-related illnesses.

Choices

Skarphol, who's been hearing a lot about the state's impending health worker crunch, said he believes that crunch is a bigger deal than helping smokers quit.

UND's med school has been sounding the alarm since at least the last legislative session. There already is a shortage of workers, according to Dean Joshua Wynne. As the Baby Boomers retire nationwide and, in their old age, require more health care, there'll be more competition for workers, which would exacerbate the shortage here. But the real kicker is that North Dakota is projected to be among the states with the highest number of elderly. This could result in rural patients and even urban patients getting less access to health care.

HB 1353 would not only pay for the med school expansion, including a new building and more faculty members, but also put in place programs to encourage health workers to head for rural areas, which face the biggest shortages.

But, there's only so much money to go around.

"It boils down to choices; that's what it's about," Skarphol said. "Is it the best use of the money? Quite frankly, you won't find willingness on the part of the Legislature to commit $104 million for the medical school without this kind of scenario."

And, he said, he feels the anti-tobacco program has gotten to most of the smokers that are ready and willing to quit -- the "low-hanging fruit," as he called it -- and what's left are the hardcore smokers that are going to be much harder to work with. There's a point of diminishing return, he said.

Heitkamp said she heard that argument in the last legislative session and smoking rates are still falling.

Reach Tran at (701) 780-1248; (800) 477-6572, ext. 248; or send e-mail to ttran@gfherald.com .