Research / Health & Human Services

Policy Analysis | May 2019

Vaping and Electronic Cigarette Legislation (2019)

Roger Moore, Policy Analyst

Electronic cigarette usage has surged in recent years, with increased rates among youth and young adults posing a particularly worrisome challenge for public health officials. According to the Centers for Disease Control and Prevention (CDC), approximately 4.9 million middle and high school students were users of tobacco products in 2018, an increase of 1.3 million from 2017. The increase – driven mostly by the growth of electronic cigarettes – impedes successful efforts by states in recent years to reduce youth tobacco usage. More than a quarter of high school students and about 7 percent of middle school students reported using tobacco products in 2018, with electronic cigarettes the most common among both demographics. Electronic cigarettes have benefits for adults using them as complete substitutes for regular cigarettes; however, the CDC and U.S. Surgeon General both warn they should not be used by youth, young adults, pregnant women and adults who do not smoke. U.S. health agencies acknowledge that further studies are needed to understand the long-term health effects of electronic cigarettes.1

In an effort to address concerns surrounding the rising popularity of vaping and electronic cigarette products among youth and young adults, many states across the South introduced and, in several cases, enacted related legislation in 2019. The legislation generally focuses on three areas:

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Policy Analysis | April 2019

School Counselor Legislation in the South

Cody Allen, Policy Analyst

Along with the more routine duties of academic and career development, school counselors also have a responsibility to assist students with personal and social development. The student-to-school counselor ratio across the South and the time allotment school counselors must spend providing direct services to students recently has drawn greater attention, as well as the need to clarify these direct services.

The American School Counselor Association (ASCA) narrows in on two best practices for states to implement regarding their school counselor programs. The first is a recommended student-to-school counselor ratio of 250-to-1. While the second is a recommendation that school counselors allocate 80 percent of their work-time to providing direct services to students and only 20 percent to non-related or administrative tasks.1

Student-to-School Counselor Ratios

In 2013 and 2017, respectively, North Carolina and Tennessee were the first states to require an 80-20 allotment for their school counselors, although neither state has yet to achieve the recommended 250‑to-1 ratio recommended by the ASCA.2

According to the ASCA and the U.S. Department of Education, based on the most recent available data, the average student-to-school counselor ratio among SLC states for the 2015-2016 school year was 411‑to-1 (slightly better than the national average of 464-to-1), with no SLC states meeting the recommended ratio. As the table illustrates, Tennessee came closest to meeting the recommended ASCA ratio.

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SLC Regional Resource | April 2019

Surprise Medical Billing in the South: A Balancing Act

Roger Moore, Policy Analyst

Balance billing is a common practice that occurs when a medically insured patient receives treatment from an out-of-network healthcare provider, either intentionally or inadvertently, and subsequently is billed the difference between the insurance company’s reimbursement rate and the amount charged by the provider. Not bound by contractual, in-network rate agreements with insurers, out-of-network providers are permitted to bill patients the remaining balance for services rendered after deductibles, copayments and coinsurance obligations have been paid. In most cases, the amount charged by a provider and the insurer’s reimbursement rate are significantly different, resulting in a confusing and/or financially distressful medical bill that must be settled or resolved by the patient.

As healthcare costs in the United States continue to climb, often forcing consumers to pay higher premiums and deductibles for care, balance billing has become a controversial and confounding policy issue involving insurers, healthcare providers, consumer advocate organizations and regulators at both the state and federal levels. Balance billing most frequently occurs after patients unintentionally receive care outside their insurance network, either during emergencies or other situations when options to choose providers are restricted.

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Katrina Shealy

South Carolina

Vice Chair
Representative Fredrick Love, Arkansas

Fredrick J. Love


Past Chair

(former) Senator
Doug Overbey


Roger Moore

Roger Moore
Policy Analyst

Ensuring the public’s general welfare and protection are among states’ most pressing concerns, with both areas constituting considerable shares of state budgets. The SLC Human Services & Public Safety Committee has a broad agenda, which takes into account the challenges states face in the areas of human services and corrections, as well as policies and programs that address them. The committee frequently undertakes assessments of pressing health issues including the national opioid crisis, organ donations and long-term care, as well as various corrections issues such as aging inmate populations, female offenders and mental health parity in prisons.

More SLC Research into Health & Human Services

Policy Analysis | April 2019

Federal Legislation on Rural Hospitals

Other | January 2019

Issues to Watch - 2019

Policy Analysis | January 2019

Medical Marijuana Laws in Southern States

SLC Issue Brief | October 2018

The Growth of Synthetic Opioids in the South

Policy Analysis | September 2018

Poverty Statistics for Southern States

Policy Analysis | August 2018

Suicide Rates in the South

Comparative Data Report | July 2018


SLC Regional Resource | May 2018

Opioids and Organ Donations: A Tale of Two Crises

SLC Special Series Report | December 2017

Long-Term Care in the South (Part II)

Comparative Data Report | July 2017


Policy Analysis | April 2017

Cross-State Health Insurance Policies

SLC Special Series Report | January 2017

Long-Term Care in the South (Part 1)

Comparative Data Report | June 2016


SLC Regional Resource | May 2016

Spread of Zika: Impact on Southern States

SLC Regional Resource | April 2015

Vapor Rising: E-Cigarettes in the SLC States

Webinar | October 2014

Food Safety Modernization Act

Comparative Data Report | August 2014


SLC Regional Resource | March 2014

A Special Condition: Medical Marijuana in SLC States

Comparative Data Report | July 2013


Comparative Data Report | July 2012


Policy Analysis | September 2011

Prospective Changes in Long-Term Care Policies

Policy Analysis | May 2011

A Prescription Drug Epidemic

Comparative Data Report | March 2011


SLC Regional Resource | July 2010

Meth: Resurgence in the South

SLC Regional Resource | January 2010

Autism and Schools

Policy Analysis | January 2010

Which SLC states have drug recycling programs?

SLC Issue Alert | January 2009

An HIV Epidemic?

Comparative Data Report | December 2008


Comparative Data Report | November 2007


Comparative Data Report | November 2006


Comparative Data Report | November 2005


Comparative Data Report | November 2004


Comparative Data Report | November 2003


Comparative Data Report | November 2002


Comparative Data Report | November 2001


Comparative Data Report | November 2000