Don’t Forget About Your State Legislators!

Most of us as orthopedic practice leaders are well accustomed to keeping up with the ever-changing developments in federal policy - Medicare reimbursement updates, CMS rulemaking, and new federal quality program requirements keep all of us up at night. However, arguably, many of the most immediate and operationally consequential decisions affecting orthopedic practices are made not in Washington, D.C., but in our local state capitals. While federal policy establishes broad reimbursement frameworks and regulatory guardrails, state legislatures exert direct influence over insurance regulation, Medicaid reimbursement, scope-of-practice laws, certificate-of-need (CON) statutes, workers’ compensation fee schedules, and medical liability environments. Additionally, the activity in our federal legislature tends to receive significantly more media attention and press than that of our state legislatures, which often requires a much more intentional effort to stay current. In short, federal policy shapes the macro environment, while state policy shapes the daily operational reality we all live in. Both are deeply important, and we cannot afford to ignore either. 

Consider insurance regulation and utilization management. Although Medicare Advantage operates under federal authority, fully insured commercial plans are regulated at the state level, including prior authorization standards, step therapy limits, network adequacy requirements, and prompt-pay statutes (KFF, 2024). We are all too familiar with the ever-growing burden of prior authorization, and evidence suggests that these requirements are associated with care delays and administrative strain for practices (AMA, 2023). Engagement with our state lawmakers can directly impact our ability to mitigate this administrative overhead, enhance our patient throughput, and improve revenue cycle performance in our practices. Several states have already enacted prior authorization reform laws designed to reduce administrative burden and improve patient access.  

Medicaid policy is another area where state legislatures play a decisive role. Although jointly funded by federal and state governments, Medicaid eligibility, managed care structures, optional benefits, and provider reimbursement rates are largely determined at the state level (CMS, 2023). For orthopedic practices, state decisions on fee schedules or supplemental payments can meaningfully impact margins and the sustainability of access. Likewise, workers’ compensation reimbursement – highly relevant to MSK care – is governed by state-specific fee schedules and dispute-resolution processes. These policies influence case mix, collections, and long-term payer strategy. 

State authority over scope-of-practice laws also carries substantial implications for orthopedic workforce models. States determine the degree of autonomy to which our APPs and Therapy team members practice, including direct access provisions and supervision requirements (National Conference of State Legislatures, 2024). These statutory frameworks affect staffing efficiency, care team design, and long-term recruitment strategy. Similarly, certificate-of-need (CON) laws directly regulate ambulatory surgery center development and capital expansion decisions. Research suggests that CON laws restrict facility footprint and market competition, with implications for access and cost (Mitchell, 2020). For orthopedic groups contemplating ASC expansion or imaging investment, state-level engagement is not optional; it is strategic. 

Finally, medical liability reform remains squarely within state jurisdiction. Damage caps, venue rules, and statutes of limitation are established through state law and directly impact malpractice premiums and risk exposure. States with more predictable liability environments often exhibit lower malpractice costs, which, in turn, shape physician recruitment and long-term practice sustainability (Mello et al., 2014). For orthopedic practices navigating rising operating expenses and workforce shortages, the cumulative effect of state legislative decisions can rival or exceed that of federal reimbursement adjustments. 

For AAOE members, the implications are clear – meaningful advocacy must extend beyond federal engagement. State legislators represent smaller constituencies, are often more accessible, and are deeply responsive to district-level economic and healthcare access needs. Orthopedic practices are often major employers, community anchors, and providers of essential MSK care. Establishing relationships with state representatives – inviting them to tour facilities, sharing data on access and employment impacts, and participating in state-level advocacy coalitions –can shape policy in ways that directly affect our daily operations and our long-term ability to thrive. If you don’t already know them well, today is a great opportunity to identify (or re-engage with) your state senator(s) and representative(s). You can typically find their contact information on your state legislative website, and a quick email or phone call to introduce yourself (or check in with them) as a healthcare leader in their district can produce significant dividends for your practice and the community you serve.  

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