A Snapshot of the Key Health Policy Issues at Play in 2018 Governors’ Races

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With elections just three weeks away, governors’ races in 36 states – with 17 open seats – are down to the wire and important health policy issues, such as Medicaid expansion, stabilizing insurance markets, public options, and prescription drug price controls, are at play in most of them. The National Academy for State Health Policy (NASHP) scanned candidates’ websites and press coverage to provide this snapshot of key health care election issues. While limited in scope and focusing only on major party candidates, this scan provides a glimpse of state campaign health issues that could be harbingers of policy action in 2019.

Addressing the opioid epidemic: No surprise to state health policy watchers, addressing the opioid epidemic remains a bipartisan priority for gubernatorial candidates. Strategies differ, but there is general support for more treatment and prevention. In Iowa, Democrat Fred Hubbell wants more support for local law enforcement and has called for the attorney general to hold pharmaceutical manufacturers accountable. In Oregon, Republican Knute Buehler seeks to cut opioid overdose deaths by 50 percent by investing in medication assisted treatment (MAT), peer counseling, and evidence-based strategies to address the crisis while incumbent Democrat Kate Brown cites her creation of a task force that is tackling these issues and her leadership to increase the availability of naloxone. In several states that have not expanded Medicaid, Democratic candidates are supporting expansion as a means to improve addiction treatment coverage.

Medicaid expansion: Seventeen states have not expanded Medicaid and that issue is front and center in many of these races. Candidates’ stances on the issue follow party lines, with Republican candidates opposing expansion and Democrats supporting it. A number of these states have open seats and highly competitive races. Whether pollsters have it right or not, these state campaigns provide insight into the current debate about Medicaid expansion.

In states with both highly competitive races and open seats, arguments for and against expansion follow similar themes. In Georgia, Republican Brian Kemp argues that the state can provide affordable health care without expanding Medicaid while Democrat Stacey Abrams has made expansion a top priority, noting its importance for coverage, mental health treatment, jobs, and support for rural hospitals. In Kansas, a recent plan to close a rural hospital is cited as one of the reasons to support expansion by Democrat Laura Kelly while Republican Kris Kobach opposes expansion. Oklahoma’s Democrat Drew Edmondson expresses strong support for expansion and he too cites the issue of rural hospitals’ financial challenges while Republican Kevin Stitt does not mention expansion on his website but seeks an audit of Medicaid spending. In Florida, Republican Ron DeSantis does not mention Medicaid on his website, but has stated opposition to expansion, while Democrat Andrew Gillum supports expansion. Democrats in South Dakota and Tennessee also support expansion and cite the plight of rural hospitals as a key factor.

In Idaho, Nebraska, and Utah, Medicaid expansion is on the ballot. In Maine, a successful citizen initiative in 2017 was stymied by outgoing Republican Gov. Paul LePage’s resistance, because the state legislature had not appropriated funds that met his conditions. After numerous court battles, LePage submitted a state plan amendment to expand Medicaid to the federal government, but urged them to deny it. In the state’s current gubernatorial race, Republican Shawn Moody mirrors LePage’s opposition while Democrat Janet Mills has made expansion a top campaign priority. In Idaho, Republican Brad Little says he will enforce expansion if that state’s ballot initiative passes, but he raises concerns about “uncertainty at the federal level.” In Nebraska, Republican incumbent Pete Ricketts strongly opposes expansion but concedes the issue is up to voters.

Medicaid work requirements: Support for work requirements generally follows party lines, but in Alabama Democrat Walt Maddox supports work requirements as part of his endorsement of Medicaid expansion. In Ohio, Republican Mike DeWine supports a “reasonable work requirement” for individuals newly covered by Medicaid expansion who are healthy and able to work.

Improving affordability of private coverage: Candidates have proposed a wide array of approaches to make health insurance coverage in the individual and small group markets more affordable.

In about one-third of the states, candidates are talking about a public option, the opportunity to buy-in to Medicaid, or other initiatives. In Alaska, Democrat Mark Begich wants to combine coverage for individuals on Medicaid, Medicare, TriHealth, and Indian Health Services into a single health care option. In Connecticut, Democrat Ned Lamont proposes strengthening the Access Health CT exchange by instituting a Medicaid buy-in option to lower costs by adding younger participants to the pool. In Illinois, Democrat J.B. Pritzker is proposing a public option/Medicaid buy-in — Illinois Cares — to allow every resident to buy low-cost health insurance. Pritzker wants to work with legislators and the health care community to design this public option as another choice on the health insurance marketplace. Minnesota’s Tim Walz, a Democrat, wants to provide a strong public health care option and suggests that MinnesotaCare, the state’s Basic Health Program, can already serve that role. In New Mexico, Democratic candidate Michelle Lujan Grisham supports “cost-effective, innovative approaches to providing affordable, high-quality health care to all New Mexicans,” including a Medicaid buy-in. Maine’s Democratic candidate Janet Mills proposes the Small Business Access Plan, a buy-in to public purchasers for small businesses and self-employed individuals.

Republican candidates, however, generally warn against a “government takeover” of health care and express concern about the high costs to taxpayers of such proposals.

A few Democrats express support for Medicare for All proposals and some identify incremental steps a state could take toward that goal. In Arizona, Democrat David Garcia supports a Medicaid buy-in as a strategy while Colorado Democrat Jared Polis seeks to “pioneer a western single-payer system” by partnering with other western states to develop a regional, multistate consortium to provide a common payer system to reduce prices, increase coverage, and improve care quality.

Premium rating rules: In Colorado, Republican Walker Stapleton said he would convene a task force to evaluate the state’s Affordable Care Act (ACA) rating regions, geographic boundaries, and departmental overlap. He opposes a single rating region supported by Democratic candidate Jared Polis, who is advocating a statewide geographic rating system and reconfiguration of rating zones with rural rate protections.

Reinsurance: In Georgia, both candidates support creating a reinsurance program to stabilize rates in the individual insurance market. Reinsurance is also supported by Democratic candidates in Colorado and Connecticut. Wisconsin Gov. Scott Walker lauds his state’s reinsurance program, Health Care Stability Plan, and notes the state is investing $200 million in market-based solutions to lower costs, which he predicts will reduce rates by 3.5 percent in 2019.

Market-based strategies: Many candidates support market-based solutions, including Colorado Republican Walker Stapleton, who would address rising health care costs for families by creating more insurance choices for consumers, such as association health plans (AHPs), short-term plans, and catastrophic coverage options. This approach is similar to strategies offered by Georgia’s Republican candidate Brian Kemp who would set “specific, achievable goals to lower the uninsured population by expanding choices” and indicates he would embrace AHPs if elected. Minnesota Republican Jeff Johnson believes MNsure has been a “complete disaster” and that new approaches are needed. He notes the “skyrocketing” cost of health insurance and lack of access to care and has proposed to request waivers to “abandon the provisions of Obamacare” because they limit choice and increase costs. He supports an interstate compact to buy and sell health insurance across state lines. Oklahoma’s Kevin Stitt similarly supports buying coverage across state lines.

A few candidates are focusing on retooling primary care. Florida Republican Ron DeSantis said he would back proposals to install direct primary care models, in which patients pay a monthly rate directly to doctors to cut out insurers. Kansas Republican Kris Kobach supports allowing patients to pay their doctors $50 a month for unlimited primary care visits.

Several candidates offer different approaches. In New Mexico, Republican Steve Pearce would encourage employers to provide health insurance by providing a tax credit for employees who work less than 20 hours per week. In New York, Republican Marc Molinaro suggests addressing high taxes on private health insurers to increase health care quality and affordability. In Rhode Island, Gov. Gina Raimondo recently issued an executive order directing the state to codify all ACA protections into state law. Her Republican opponent, Allan Fung, wants to keep the state-based exchange and control of insurance regulation in-state, and does not want to change the existing protections “whether it’s pre-existing conditions” or “taking away coverage” or changes in Medicaid eligibility. Maryland Gov. Larry Hogan opposes any changes to the ACA that would “jeopardize Marylanders’ access to quality health care” and supports stabilizing the insurance market and keeping premiums down. In contrast, South Carolina Gov. Henry McMaster states that “Obamacare was an unprecedented encroachment on state sovereignty” and wants to ensure greater access and affordability through removal of anti-free market mandates and regulations to allow for investment, expansion, and ingenuity to lower health care costs. Maine’s Democratic candidate Janet Mills would protect against rollbacks of ACA protections and also supports “well-regulated” AHPs.

Reducing prescription drug costs: Addressing rising pharmaceutical costs is another issue that has bipartisan support. A number of candidates from both parties indicated support to lower costs on their websites while others present specific proposals.

In Ohio, Republican Mike DeWine advocates for greater transparency of drug prices by bringing more attention on pharmacy “middle men.” His Democratic opponent, Richard Cordray, has also supported more transparency around pharmacy benefit manager (PBM) activities. In Colorado, Democrat Jared Polis seeks to improve support for the state’s all-payer claims database (APCD) and to use data to identify health care savings. He also advocates for increased transparency by requiring drug companies to publicly disclose pricing and would crack down on price gouging by forcing drug companies to justify price increases. Additionally, he proposes to set up a framework to import prescription drugs from Canada. Other Democratic candidates also support importation, including Drew Edmonson of Oklahoma, Tony Evers of Wisconsin, as well as Ben Jealous of Maryland, who supports a Prescription Drug Affordability Plan that requires drug companies to give notice when increasing prices and drug spending caps for Medicaid. Connecticut Democrat Ned Lamont wants to “take strong and multipronged action to reduce drug prices” and supports pricing transparency for manufacturers, including requirements that drug companies include their wholesale prices in advertisements. He also wants to limit coupon use in private insurance and cap out-of-pocket pharmaceutical costs. In contrast, his Republican opponent, Brad Stefanowski, opposes government regulation of prescription drug costs.

Two candidates propose expanding the state’s public purchasing role to lower costs. Nevada Democrat Steve Sisolak proposes creating Silver State Scripts — a consortium of private and public health plans that will negotiate for lower drugs prices, while New Mexico Democrat Michelle Lujan Grisham seeks to pool state resources to reduce drug prices.

In Maine, Republican Shawn Moody proposes to lower prescription drug costs by providing greater access to generic drug alternatives. Democrat Janet Mills has a multifaceted plan to lower drug prices that includes investigating pooling public purchasers, increasing transparency and following the work in other states on importation and establishing payment caps to “step in quickly if solutions pioneered elsewhere take hold”. In Wisconsin, Gov. Scott Walker wants to make permanent a waiver for SeniorCare, a program to make prescription drugs more affordable for seniors, while Democrat Tony Evers proposes a rate review board and banning PBM gag clauses. In Oregon, Republican Knute Buehler has made drug pricing a major campaign issue. He wants to prosecute leaders of price-gouging pharmaceutical companies and would like to adopt a single formulary for all state taxpayer-funded drug purchasing. Incumbent Kate Brown cites her work in the past to support price transparency.

Social determinants of health: A number of candidates have targeted social determinants of health, including Arkansas Democrat Jared Henderson who proposes reducing teenage pregnancy and childhood poverty as ways to address long-term health care spending without reducing Medicaid enrollment. In Ohio, Republican Mike DeWine has a plan for wellness programs that would require Medicaid managed care plans to provide education and promote healthy benchmarks geared towards upstream prevention efforts. Colorado Democrat Jared Polis suggests moving toward global budgeting for hospitals, which would provide them with a set amount of revenue that could incentivize efficiency, innovation, and a focus on social determinants of health and preventive care. Oregon Republican Knute Buehler wants to coordinate investments, set financial expectations, and determine specific metrics in social determinants of health, such as workforce training, employment, community engagement, and housing. Democrat Karl Dean of Tennessee supports preventive health care and promoting healthy lifestyles, and as governor would focus on preventing childhood obesity because of its link to both chronic health problems later in life as well as social and emotional issues.

Delivery system and payment reforms: States have been actively engaged in a variety of reforms designed to improve how care is delivered and paid for –moving from a volume- to a value-based system – and a number of candidates have embraced these efforts. In Colorado, both candidates refer to the lessons learned from the state’s State Innovation Model (SIM) initiative. Democrat Jared Polis wants to use lessons from SIM to increase access to integrated physical and behavioral health care and supports moving Colorado Medicaid to a bundled payment system. He also proposes global budgeting for hospitals and using health information technology to measure hospital care quality and tie payments to community health improvement. Republican Walker Stapleton wants to build on the success of the state’s SIM work and continue expanding the state’s Regional Accountability Entities to make sure reimbursement systems promote the best patient outcomes. Ohio Democrat Richard Cordray plans to reform the Medicaid payment system to incentivize primary and preventive care in physical and behavioral health, and would invest in high-quality, value-based programs. Oregon Republican Knute Buehler wants to prepare for a third generation of Coordinated Care Organizations (CCOs) by aligning early learning hubs, regional solutions, and related social and health services. He also proposes to reorganize Medicaid mental health services payment and delivery to fully integrate mental and physical health through CCOs (with counties continuing to serve as providers) and tie CCO funding to outcomes. Tennessee Democrat Karl Dean would continue the state’s work to promote health care value over volume, which has included phased implementation of episodes of care for TennCare enrollees.

This snapshot suggests governors’ races are fueling spirited discussions about health policy and promises a lively 2019 as policymakers continue to address how to provide affordable, high-quality health care and improve population health. New governors’ ideas will be considered by state legislatures, whose political make-up will also likely change, as 80 percent of all state lawmakers are up for election in November. As voters make their choices, NASHP will continue to track and support policymakers who advance solutions to the current challenges of health care access, cost, and quality, and help identify new opportunities for state innovation.