North Dakota
North Dakota joins states challenging health care protections for transgender Americans
BY: ANNELISE HANSHAW
BISMARCK, N.D. (North Dakota Monitor) – North Dakota has joined a coalition of seven states challenging a rule by the Biden administration that would preempt state restrictions on gender-affirming care.
The legal challenge, which is led by Missouri Attorney General Andrew Bailey, was filed in United States District Court for the Eastern District of Missouri on Wednesday. The states are seeking to block the regulation and prevent the federal government from enforcing similar mandates.
The rule seeks to add protections to a section of the Affordable Care Act that prevent health care providers who discriminate on the basis of gender identity or sexual orientation from receiving federal funding, including through Medicaid and the Children’s Health Insurance Program.
The rule was set to go into effect July 5, with some provisions beginning later. But another coalition of attorneys general succeeded in their petition to block its implementation just two days prior. The judge in that case cited the recent U.S. Supreme Court decision to overturn “Chevron Deference,” a precedent that gave regulatory authority to federal agencies when statute is unclear.
Bailey, along with attorneys general from Utah, North Dakota, South Dakota, Iowa, Idaho and Arkansas, argues that the rule conflicts with their states’ restrictions on gender-affirming care for minors. Each has varying restrictions on payments for gender-affirming treatment, with Missouri blocking payment for all treatments for medical transition through Medicaid and CHIP.
“… states will be unable to enforce these duly enacted laws and longstanding policies without coming into conflict with the rule,” the attorneys general wrote in the lawsuit.
The American College of Pediatricians joins the attorneys general as a plaintiff. The ACPeds is a group of 400 physicians and other healthcare professionals in 47 states with a history of anti-LGBTQ advocacy.
“ACPeds members categorically do not provide medical interventions or referrals for, and do not facilitate or speak in ways that affirm the legitimacy of, the practice of ‘gender transition,’” the attorneys general wrote.
The lawsuit alleges that the organization’s pediatricians would suffer “significant financial harm to lose eligibility to participate in federal healthcare programs such as Medicare, Medicaid, and CHIP.”
One pediatrician in Utah is quoted in the lawsuit saying he would not “self-censor his opinions on transition efforts if the rule goes into effect.”
Predicting his noncompliance with the rule, the Utah pediatrician “faces the prospect of no longer caring for his patients, being fired from his employment and being unable to practice medicine in most settings,” the attorneys general wrote.
The rule violates physicians’ freedom of assembly, the lawsuit states, “by coercing them to participate in facilities, programs, groups and other healthcare-related endeavors that are contrary to their views and that express messages with which they disagree.”
The lawsuit also says it “coerces ACPeds members’ speech.”
“By forcing ACPeds members to tell patients directly, on their walls, and on their websites that they do not discriminate on the basis of gender identity, the rule forces ACPeds members to speak falsely, and it forces ACPeds members to fatally undermine their communication of their own medical ethical standards,” it says.
Beyond questions of constitutionality, the attorneys general allege that the rule goes beyond congressional authorization.
The rule interprets gender identity as protected by both including gender dysphoria as a disability and interpreting sex discrimination to include gender identity. The attorneys general disagree with this application.
Key to the case will be the judge’s interpretation of the 2020 U.S. Supreme Court Case Bostock v. Clayton County, in which a majority of justices ruled that gender identity was protected under Title VII, which is on employment discrimination.
The rule leans on some courts’ interpretation that transfers the Bostock decision to Title IX and the Affordable Care Act, according to its publication in the Federal Register. But the attorneys general cite decisions from judges in red states that do not allow Bostock to apply outside of Title VII.
The Department of Health and Human Services, which is the defendant in the litigation, did not respond to a request for comment.
North Dakota
European potato company plans first U.S. production plant in North Dakota
Agristo, a leading European producer of frozen potato products, is making big moves in North America. The company, founded in 1986, has chosen Grand Forks, North Dakota, as the site for its first U.S. production facility.
Agristo has been testing potato farming across the U.S. for years and found North Dakota to be the perfect fit. The state offers high-quality potato crops and a strong agricultural community.
In a statement, Agristo said it believes those factors make it an ideal location for producing the company’s high-quality frozen potato products, including fries, hash browns, and more.
“Seeing strong potential in both potato supply and market growth in North America, Agristo is now ready to invest in its first production facility in the United States, focusing on high-quality products, innovation, and state-of-the-art technology.”
Agristo plans to invest up to $450 million to build a cutting-edge facility in Grand Forks. This project will create 300 to 350 direct jobs, giving a boost to the local economy.
Agristo is working closely with North Dakota officials to finalize the details of the project.
Negotiations for the plant are expected to wrap up by mid-2025.
For more information about Agristo and its products, visit www.agristo.com.
Agristo’s headquarters are located in Belgium.
North Dakota
Audit of North Dakota state auditor finds no issues; review could cost up to $285K • North Dakota Monitor
A long-anticipated performance audit of the North Dakota State Auditor’s Office found no significant issues, consultants told a panel of lawmakers Thursday afternoon.
“Based on the work that we performed, there weren’t any red flags,” Chris Ricchiuto, representing consulting firm Forvis Mazars, said.
The review was commissioned by the 2023 Legislature following complaints from local governments about the cost of the agency’s services.
The firm found that the State Auditor’s Office is following industry standards and laws, and is completing audits in a reasonable amount of time, said Charles Johnson, a director with the firm’s risk advisory services.
“The answer about the audit up front is that we identified four areas where things are working exactly as you expect the state auditor to do,” Johnson told the committee.
The report also found that the agency has implemented some policies to address concerns raised during the 2023 session.
For example, the Auditor’s Office now provides cost estimates to clients before they hire the office for services, Johnson said. The proposals include not-to-exceed clauses, so clients have to agree to any proposed changes.
The State Auditor’s Office also now includes more details on its invoices, so clients have more comprehensive information about what they’re being charged for.
The audit originally was intended to focus on fiscal years 2020 through 2023. However, the firm extended the scope of its analysis to reflect policy changes that the Auditor’s Office implemented after the 2023 fiscal year ended.
State Auditor Josh Gallion told lawmakers the period the audit covers was an unusual time for his agency. The coronavirus pandemic made timely work more difficult for his staff. Moreover, because of the influx of pandemic-related assistance to local governments from the federal government, the State Auditor’s Office’s workload increased significantly.
Gallion said that, other than confirming that the changes the agency has made were worthwhile, he didn’t glean anything significant from the audit.
“The changes had already been implemented,” he said.
Gallion has previously called the audit redundant and unnecessary. When asked Thursday if he thought the audit was a worthwhile use of taxpayer money, Gallion said, “Every audit has value, at the end of the day.”
The report has not been finalized, though the Legislative Audit and Fiscal Review Committee voted to accept it.
Audit of state auditor delayed; Gallion calls it ‘redundant, unnecessary’
“There was no shenanigans, there were no red flags,” Sen. Jerry Klein, R-Fessenden, said at the close of the hearing.
Forvis representatives told lawmakers they plan to finish the report sometime this month.
The contract for the audit is for $285,000.
Johnson said as far as he is aware Forvis has sent bills for a little over $150,000 so far. That doesn’t include the last two months of the company’s work, he said.
The consulting firm sent out surveys to local governments that use the agency’s services.
The top five suggestions for improvements were:
- Communication with clients
- Timeliness
- Helping clients complete forms
- Asking for same information more than once
- Providing more detailed invoices
The top five things respondents thought the agency does well were:
- Understanding of the audit process
- Professionalism
- Willingness to improve
- Attention to detail
- Helpfulness
Johnson said that some of the survey findings should be taken with a “grain of salt.”
“In our work as auditors, we don’t always make people happy doing what we’re supposed to do,” he said.
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North Dakota
'False promise' or lifesaver? Insulin spending cap returns to North Dakota Legislature
BISMARCK — A bill introduced in the North Dakota House of Representatives could cap out-of-pocket insulin costs for some North Dakotans at $25 per month.
The bill also includes a monthly cap for insulin-related medical supplies of $25.
With insulin costing North Dakota residents billions of dollars each year,
House Bill 1114
would provide relief for people on fully insured plans provided by individual, small and large group employers. People on self-funded plans would not be affected.
“I call insulin liquid gold,” Nina Kritzberger, a 16-year-old Type 1 diabetic from Hillsboro, told lawmakers. “My future depends on this bill.”
HB 1114 builds on
legislation
proposed during the 2023 session that similarly sought to establish spending caps on insulin products.
Before any health insurance mandate is enacted,
state law
requires the proposed changes first be tested on state employee health plans.
As such, the legislation was altered to order the state Public Employees Retirement System, or PERS, to introduce an updated bill based on the implementation of a $25 monthly cap on a smaller scale.
The updated bill — House Bill 1114 — would bring the cap out of PERS oversight and into the North Dakota Insurance Department, which regulates the fully insured market but not the self-insured market.
Employers that provide self-insured health programs use profits to cover claims and fees, acting as their own insurers.
Fully insured plans refer to employers that pay a third-party insurance carrier a fixed premium to cover claims and fees.
“It (the mandate) doesn’t impact the entire insurance market within North Dakota,” PERS Executive Director Rebecca Fricke testified during a Government and Veterans Affairs Committee meeting on Thursday, Jan. 9.
Blue Cross Blue Shield Vice President Megan Hruby told the committee that two-thirds of the provider’s members would not be eligible for the monthly cap, calling the bill a “false promise.”
“We do not make health insurance more affordable by passing coverage mandates, as insurance companies don’t pay for mandates. Policy holders pay for mandates in the form of increased premiums,” Hruby said.
She touted the insurance provider having already placed similar caps on insulin products and said companies should be making those decisions, not the state government.
Sanford Health and the Greater North Dakota Chamber also had representatives testify against the bill.
Advocates for the spending cap said higher premiums are worth lowering the cost of insulin drugs and supplies.
“One of the first things that people ask me about is, ‘Why should I pay for your insulin?’ And my response is, ‘Why should I have to pay for your premiums?’” Danelle Johnson, of Horace, said in her testimony.
If adopted and as written, the spending caps brought by
House Bill 1114
would apply to the North Dakota commercial insurance market and cost the state around $834,000 over the 2025-27 biennium.
According to the 2024 North Dakota diabetes report,
medical fees associated with the condition cost North Dakotans over $306 billion in 2022.
The state has more than 57,200 adults diagnosed with diabetes, and a staggering 38% have prediabetes — a condition where blood sugar levels are high but not high enough to cause Type 2 diabetes.
Nearly half of those people are adults 65 years old or older.
North Dakotan tribal members were also found to be twice as likely to have diabetes compared to their white counterparts.
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