This article is part one of a mini-series documenting the seven bills that Governor Burgum vetoed in the 2023 legislative session. For the other articles, click here.
Representative Dwight Kiefert, Representative Karen A. Anderson, Senator Cole Conley, Representative Karen M. Rohr, Representative Matthew Ruby, Representative Bill Tveit, Representative Don Vigesaa, Representative Robin Weisz, and Senator Michael A. Wobbema
The bill read that a health insurer, including the Medicaid program, which is part of an integrated delivery network or a policy directly affiliated with or administered for a health care provider may not obstruct patient choice by excluding a health care provider licensed under the laws of this state from participating on the health insurer's panel of providers if the provider is located within the geographic coverage area of the health benefit plan and is willing and fully qualified to meet the terms and conditions of participation, as established by the health insurer.
Currently, North Dakota has only one health care system that offers both health care services (a provider) and health insurance plans (a payer) and therefore meets the bill’s definition of “integrated delivery network.”
House Bill 1416 targets only one health insurance plan offered in North Dakota and directly risks increasing health insurance costs for over 13,000 North Dakotans. These citizens made the personal choice to enroll in a health care plan with a narrow (versus broad) provider network to achieve paying substantially lower health insurance premiums. It should be noted that this plan’s “narrow” network of approximately 3,500 North Dakota providers includes 1,600 providers who are not employees of the integrated delivery network offering the plan.
Multiple health insurers serving North Dakota also offer reduced-price premium health insurance plans tied to narrow provider networks. However, because those payers would not be subject to the restrictions in House Bill 1416, this bill, if signed, would likely invite legal challenges based on North Dakota’s constitutional prohibition on “special legislation” which targets one specific business or entity.
According to public testimony provided by the state’s lone integrated delivery network, employers participating in its narrow plan are required to offer employees the broad provider network alongside the narrow provider network. At the end of the day, this is the consumer’s decision, and each choice must be weighed according to personal preferences, circumstances and budgets.
Vertical integration in the U.S. health care industry, for better or worse, has accelerated since the implementation of the Affordable Care Act in 2010. Hundreds of integrated delivery networks now exist across the United States. While currently we have only one integrated delivery network in North Dakota, we could see additional health care service providers align with insurance companies to offer reduced-cost, narrow network health insurance plans. Such competition from new entrants in North Dakota would be constrained by the narrow limitation of House Bill 1416.
The extensive testimony and lobbying on both sides of this bill is part of a larger, ongoing, important debate about how to achieve health care affordability, accessibility and quality for all our citizens, including in our rural and tribal areas. This larger debate in our Capitol and across our country reflects genuine concerns about the market power and the potential conflicts of interest of vertical integration between payers and providers.
However, this bill does not resolve or solve those concerns. Currently, independent providers are included in many broad network insurance offerings from North Dakota insurers. Again, all this half-page bill would accomplish is to eliminate one reduced-cost plan currently purchased and in use by 13,000 citizens, which is less than 2 percent of all North Dakotans on health insurance plans in North Dakota.
We commend the Legislature for attempting to address concerns about the market power of vertical integration in health care. We encourage the Legislature to create a joint legislative/executive branch task force including our independently elected Insurance Commissioner to build upon prior efforts and continue a comprehensive review of affordability, accessibility and quality of North Dakota’s health systems during the interim.
The Legislature should insist that payers and providers come to the table with transparency and direct the task force to bring forward recommendations to the 69th Legislative Assembly to reduce costs, enhance patient outcomes and improve health for all North Dakotans.
For the reasons stated above, House Bill 1416 is vetoed.
Representative Ben Koppelman, Representative Larry Bellew, Senator David A. Clemens, Representative Matt Heilman, Representative Pat D. Heinert, Representative Jim Kasper, Senator Doug Larsen, Representative Scott Louser, Senator Scott Meyer, Senator Bob Paulson, Senator Shawn Vedaa, andSenator Michael A. Wobbema
This bill read that a ranked-choice voting method that allows voters to rank candidates for an office in order of preference and has ballots cast tabulated in multiple rounds following the
elimination of a candidate until a single candidate attains a majority may not be used
in determining the election or nomination of any candidate to any local, state, or
federal elective office. An approval voting method that allows voters to vote for all the candidates the voter approves of in each race and the candidates receiving the most votes will be elected until all necessary seats are filled in each race may not be used in determining the
election or nomination of any candidate to any local, state, or federal elective office. Pursuant to a home rule charter or not, an ordinance enacted or adopted by a county, city, or other political subdivision which is in conflict with this section is void, unless the ordinance was adopted on or before February 1, 2023.
House Bill 1273 undermines local control of local political subdivisions exercising their granted powers under home rule charter, specifically prohibiting using an approval voting method or ranked-choice voting method in local elections. This bill also applies restrictions to local elections held by counties, cities and other political subdivisions, regardless of whether they have adopted a home rule charter.
To be clear, under existing law, counties and cities currently do not – and should not – have
authority to implement approval voting or ranked-choice methods for state and federal elected office. Home rule authority applies only to local elections.
House Bill 1273 blatantly infringes on local control and the ability of residents in home rule cities to determine which method of local city election is best for their communities based on the unique aspects of city elections, including those that often have a very large field of candidates elected at-large and not by wards, with no party affiliation and no primary or runoff elections.
Currently, the mantra of “one person, one vote” is often cited in opposition to approval voting. However, in city and county elections using the current plurality voting method in North Dakota, individual voters already often have the opportunity to vote for multiple candidates for two, three, or four seats on a city council or county commission, for example. Only one political subdivision, the city of Fargo, uses approval voting, having adopted this method through a citywide ballot measure in 2018 approved by 63.5% of those voting on the measure. Ranked-choice voting is not used by any political subdivision in North Dakota.
House Bill 1273 – sponsored by a dozen legislators but none of the 18 legislators who represent Fargo – subverts the will of Fargo residents and overturns the supermajority approval of their 2018 ballot measure five years later.
House Bill 1273 also rolls back the power granted to all 155 cities – across every North Dakota legislative district – that have adopted a home rule charter under North Dakota Century Code 40-05.1-06 Subsection 9, which states that home rule cities have authority “to provide for all matters pertaining to city elections, except as to qualifications of electors.” Withdrawing this authority after it has already been exercised to carry out the supermajority will of voters is an egregious example of state overreach and demonstrates a lack of respect for local control. Further, instead of taking the opportunity to respect the decision made by over 30,000 Fargo voters and include a grandfather clause in House Bill 1273, the Legislative Assembly is attempting to move the goalposts after the rules were set and legally Followed.
To nullify the legitimate votes of tens of thousands of North Dakota citizens and prevent other home rule cities and counties from exercising their home rule authority over elections of their own elected officials is improper and invites legal action against the state. In North Dakota, we frequently rail against federal overreach that impacts states’ rights. If we truly believe in limited government and local control, we can begin by honoring the boundaries, intent and spirit of home rule charters, especially when there is no evidence of any harm having occurred from trusting the residents of cities to have self-determination within the bounds of their home rule charters.
For the reasons stated above, House Bill 1273 is vetoed.
This article is part one of a mini-series documenting the seven bills that Governor Burgum vetoed in the 2023 legislative session. For the other articles, click here.
