In their 2019 state of the state speeches, 13 governors addressed social equity, acknowledging that reducing inequities and improving opportunities for all residents improves lives and health outcomes. Two of them — Indiana and Minnesota – offer examples of how states are orchestrating their legislative and administrative efforts to reduce health disparities and promote social equity.
Of the many factors that influence health, 80 percent occur outside of the health care system, such as access to safe and affordable housing, high-quality education, and employment opportunities. Across the nation, health disparities persist where racial and ethnic discrimination, gender inequities, class distinctions, and other barriers systemically keep certain people from the opportunities and resources needed to live long and healthy lives.
These health disparities can be observed and tracked by state, county, zip code, or neighborhood. Indiana and Minnesota state policymakers are using budget appropriations, executive orders, and legislation to improve social equity.
Gov. Eric Holcomb and a group of Indiana state leaders are tackling disparities in infant mortality under the umbrella of health equity. Their goal is to lower the state’s rate of infant mortality across all zip codes by improving services for expecting mothers.
In May, Gov. Holcomb signed a bill to address infant mortality and establish a perinatal navigator program. The program engages pregnant women in evidence-based, early prenatal care to improve outcomes regardless of where a woman lives by providing referrals for wraparound services and community-based, home-visiting programs. There is an evidence base to support the positive impact on birth outcomes of community-based programs like these that address social determinants of health. The new law also establishes a program to provide more nurse partners and community health workers to coach, care for, and educate young women during pregnancy.
Across the United States, African Americans experience a higher infant mortality rate than any other racial group — and this is true in Indiana as well. From 2013 to 2015, Indiana’s infant mortality rate averaged 7.13 per 1,000 live births, compared to the 2015 national average of 5.90 per 1,000 live births. The non-Hispanic black population infant mortality rate in Indiana was much higher, at 13.26 per 1,000 live births. Indiana’s plan to boost resources for pregnant women and to engage women sooner in supportive care is designed to make pregnancy outcomes — and overall health outcomes — more equitable for all.
In Minnesota, Gov. Tim Walz and state leaders are using a variety of levers to address the structural components of inequity. The initiatives proposed in the budget or enacted through executive orders are designed to reduce disparities in educational achievement and hiring experienced by racial minorities in Minnesota. Though not directly tied to health, these disparities can lead to income inequality and other stressors that are strongly associated with poor health outcomes — so Minnesota’s upstream approach has the potential to improve health across the state.
Minnesota’s state budget, approved in late May, included a 2 percent increase in per-pupil funding to public schools, which is part of Gov. Walz’s plan to reduce disparities in educational achievement by improving school resources across the state. He also proposed a Community Solutions Fund in his budget that would provide local groups with grants to help them address children’s health care issues in a flexible way.
Gov. Walz also issued an executive order at the beginning of his term creating the Diversity, Inclusion and Equity Council. Headed by Chris Taylor, the state’s new Chief Inclusion Officer, the council will focus in part on diversifying the state workforce as another strategy to address historic structural inequities. The council’s long-term approach to address disparities is designed to level Minnesota’s economic and social playing fields and improve social equity and health outcomes for all.
The approaches taken by Minnesota’s and Indiana’s governors demonstrate how state leaders can push for social equity with targeted or broad systemic changes to improve overall social conditions. As more policymakers adopt an upstream approach to health and address inequities, they can reduce economic, social, and discrimination-based obstacles to generate better health outcomes for all.
Addressing lead hazards today generates future economic benefits and improved health outcomes for children. In partnership with the Health Resources and Services Administration, NASHP is publishing a series of case studies highlighting state initiatives to promote lead screening and treatment. This study explores Indiana’s efforts to address this issue within its Medicaid and Children’s Health Insurance Program.
- View or download: State Levers to Promote Lead Screening and Treatment: Maryland’s Strategies
- View or download: Medicaid and Children’s Health Insurance Program Levers to Promote Lead Screening and Treatment: Indiana’s Experience
- To learn about other state initiatives, read NASHP’s 50-State Scan of State Health Care Delivery Policies Promoting Lead Screening and Treatment.
The National Academy for State Health Policy examined how Indiana and Alaska leverage their resources and build new partnerships to implement innovative, cross-agency approaches to bolster their health care workforces. These case studies explore:
- Cross-agency coalitions that develop and implement innovative workforce strategies;
- Opportunities to use data to identify and address workforce shortages;
- Strategies to support and promote a non-traditional health care workforce; and
- Options to support education and training for current and future health care workers.
Read or download: Case Study: How Indiana Addresses Its Health Care Workforce Challenges
Read or download: Case Study: How Alaska Addresses Its Health Care Workforce Challenges
- Read State Agencies Partner to Address Health Care Workforce Shortages, which highlights state and federal resources, such as Workforce Innovation and Opportunity Act funding, Section 1115 waivers, and federal and state loan repayment programs, that can be used to address workforce challenges.
Review presentations from #NASHPCONF18’s session: May the (Work) Force Be With You.
Twelve governors flagged health care workforce needs as a key priority in their 2018 State of the State Addresses, an increase from only eight in 2017. States across the country are experiencing shortages of health care professionals, with the gap projected to increase in the coming years as America’s population continues to age. These workforce shortages can be more acute in rural areas and in specific fields (behavioral health, oral health, and primary care), and can affect access to care, cost of care, and state delivery system reform efforts. To address critical health care workforce shortages, policymakers are working across state agencies, aligning resources, data, and expertise to better address the problem.
States have a number of resources, typically dispersed across multiple agencies, which can be used to address healthcare workforce, including:
- Every four years the governor’s office in each state submits their Work Force Innovation and Opportunity Act (WIOA) state plan, which sets the state’s workforce priorities; some states (for instance, Montana) have opted to include healthcare as a focus area. To support these priority areas, governors can allocate up to 15 percent of state WIOA formula funds to statewide workforce development initiatives.
- State departments of labor often administer programs, such as employment services and training and skill building programs for adults, dislocated workers, and youth.
- State departments of education often administer vocational rehabilitation services programs, which provide employment, training, and support services to individuals with disabilities, as well as adult education programs. State universities, community colleges, and/or departments of education can develop and administer career pipeline or pathway programs, which introduce students to health professions or provide adults with career training opportunities. Medical and nursing schools across the country serve as Area Health Education Centers (AHECs) to provide resources and training for health careers to their communities.
- State departments of health in most states manage their state loan repayment programs, including any federal matching funds, and the Primary Care Offices are responsible for submitting applications for Health Professional Shortage Area (HSPAs) designations and resources.
- Medicaid often contributes to state graduate medical education (GME) funding. Medicaid can also incorporate workforce initiatives into 1115 Demonstration waivers.
A Closer Look at Indiana
To avoid silos, states, often through governors’ initiatives, are bringing together agencies such as health and human services, labor, and education (including state universities) to maximize available resources and ensure a coordinated approach. In one leading state, Indiana’s then-Governor Mike Pence established the Indiana Governor’s Health Workforce Council. The Council brings together a diverse group of stakeholders, including state agencies, legislators, state universities, professional associations, and employers, to identify and coordinate on the state’s healthcare workforce needs and solutions. The workgroup has prioritized several areas, including:
- Pre-nursing certificate pathway. In response to recommendations and findings from the Council’s Education, Pipeline, and Training Taskforce, Ivy Tech Community College established a pre-nursing certificate pathway for certified nursing aides (CNAs) to make it easier for them to become licensed practical nurses (LPNs) or registered nurses (RNs).
- Community health worker (CHW) certification and reimbursement. The Council has convened a Community Health Worker Workgroup, which is working to develop a statewide definition and certification requirements. The Council has also been collaborating with Medicaid to develop a reimbursement methodology for CHWs.
- Telehealth. The Council’s Mental and Behavioral Health Workforce Taskforce also put forward recommendations that led to the adoption of House Enrolled Act 1337, which allows for the delivery of some mental health and addiction treatment services through telehealth.
Cross-agency partnerships provide a foundation for states to implement workforce development programs and reforms, such as those in Indiana. As part of a cooperative agreement with the HRSA, NASHP is researching state partnerships across the country, learning how they have used diverse governance models and policy levers to address state healthcare work force needs. Look for a series of state case studies and other NASHP resources that explore these issues. NASHP’s 31st Annual State Health Policy Conference, taking place on Aug. 15-17, 2018, will also feature sessions on state strategies to address health care workforce challenges. Register here.
Stay tuned to NASHP’s website and sign up for the weekly e-newsletter for updates and information on building your state’s health care workforce.
The following information is paired with our blog, Emerging Themes in Proposed State Medicaid Waivers.
Key Pending Waiver Requests for ACA Medicaid Expansion Eligibility Groups
- Seeking to add work requirements as a condition of eligibility:
- Arizona (20 hours/week for school/job training; unspecified for employment or job search)
- Arkansas (80 hours/month)
- Indiana (Average of 20 hours/week)
- Kentucky (5 hours/week increasing to 20 hours/week after first year of enrollment)
- Requesting to cap eligibility for expansion population to 100% FPL: Arkansas
Arizona originally implemented the ACA’s Medicaid expansion without a waiver (and prior to the ACA the state had expanded coverage to childless adults up to 100% FPL). In 2015 under the administration of Governor Ducey, the state developed a plan requiring expansion enrollees to contribute premium payments to health savings accounts, pay copayments of up to three percent of income, as well as adding work requirements and limits on lifetime enrollment in the program for most able-bodied adults to five years. Arizona’s waiver was approved in September 2016, although the work requirements and time limits on enrollment were denied. Due to a 2015 state law, Arizona’s Medicaid agency is required to annually request from CMS the ability to implement certain eligibility requirements for able-bodied adults. This includes the previously rejected work requirements and time limits, as well as prohibitions on enrollment for one year for individuals who do not report income changes or inaccurately indicate compliance with the work requirements. The draft waiver indicates individuals can meet the work requirements by being employed, verifying that they are actively seeking work, or attending school and/or a job training program at least 20 hours/week. Public comments on the current draft waiver were accepted through March 2017, and it is anticipated the state will submit the proposal to CMS soon.
Arkansas’ current Medicaid expansion waiver, called Arkansas Works, is an extension of, and modification to, the state’s original 2014 Medicaid expansion waiver that most notably uses Medicaid funds to enroll the state’s Medicaid expansion population into ACA marketplace/qualified health plan (QHP) coverage. Arkansas Works was approved in December 2016 and is effective through 12/31/21, and includes a premium assistance program for employer-sponsored insurance (ESI), premiums for individuals above 100% FPL, incentives for timely premium payments and healthy behavior activities, a conditional waiver of retroactive coverage, and work referrals. Although Arkansas Works had been approved just months before, in March 2017 Governor Hutchinson outlined potential amendments to Arkansas Works. Most notably the proposed changes included adding a work requirement for most non-disabled adults as a condition of eligibility and capping eligibility to 100% FPL. (An estimated 20 percent of individuals in Arkansas Works have incomes between 100-138% FPL; under the proposal these individuals would be eligible for subsidized marketplace coverage.) Because these proposed changes required state legislative action, a special legislative session was convened and legislators passed a bill that the governor signed into law in May. The state has posted the draft waiver for public comment through mid-June. Individuals who are subject to the employment requirements must work or be engaged in certain educational, job training or job search activities for at least 80 hours per month to maintain coverage. If they do not meet these requirements for any three months during a plan year, individuals will be disenrolled and not allowed to reenroll until the next plan year. Through the waiver the state also proposes to eliminate retroactive coverage as well as its ESI premium assistance program and enroll participating and eligible individuals into QHP coverage.
A key feature of the Healthy Indiana Plan 2.0 (HIP 2.0) Medicaid expansion waiver, initially approved in 2015, is enrollee premium contributions to Personal Wellness and Responsibility (POWER) accounts along with a high-deductible plan. Contributions to POWER accounts are required as a condition of eligibility for individuals above 100% FPL, and these individuals can be disenrolled from coverage for six months for unpaid premiums unless they meet certain exceptions. CMS denied Indiana’s request to include a work referral as a condition of eligibility. However, separate from the expansion waiver, the state refers adults covered by Medicaid who are unemployed or working less than 20 hours a week to a voluntary work search and job training program. In January 2017 the state submitted a waiver extension application to continue the HIP 2.0 plan until January 2021, which included requirements for managed care entities to create incentive programs designed to promote employment. The state took further steps related to employment conditions in May by adding an amendment to the application to include work requirements as a condition of eligibility for most non-disabled enrollees. Specifically, individuals will be required to work on average 20 hours per week over eight months during the eligibility period. Individuals can also meet the requirement by participating in the state’s job search and training program or by being enrolled in part-time or full-time education.
Under the administration of former Governor Beshear, Kentucky implemented the ACA’s Medicaid expansion without a waiver. However, after Governor Bevin took office the state submitted a Section 1115 wavier to CMS in August 2016 to modify the state’s Medicaid expansion model, incorporating many of the features of Indiana’s waiver. As of mid-June 2017 the waiver is still pending CMS approval, but it is anticipated that CMS will respond this month.
Through the waiver, the state proposes to create both high deductible accounts for most enrollees and incentive (My Rewards) accounts for all enrollees. The state would contribute $1,000 to the deductible accounts, with funds to be used for non-preventive health care services. Up to 50 percent of any remaining funds from the deductible account can be transferred at the end of the benefit period to the My Rewards accounts. Enrollees can also earn funds for the My Rewards accounts by completing certain health-focused or community engagement activities. Funds in these accounts can be used to purchase benefits not covered (such as dental, vision, over-the-counter medications and gym memberships) and would be deducted for non-emergency use of the ER. The waiver proposal also includes premiums for most non-disabled adults based on income in lieu of copayments, although individuals below 100% FPL can opt to pay Medicaid copayments instead of premiums. For individuals above 100% FPL, premium payments would be a condition of eligibility, and coverage would not begin until after premium payment. These individuals could be disenrolled for nonpayment after a grace period and not permitted to re-enroll for six months or until premiums paid in full and the enrollee completes a financial or health literacy course. Additionally, individuals above 100% FPL would have increasing premiums during their third year of enrollment to greater than 2 percent of income (which would result in higher premiums than those on the marketplace at this income level). The proposal also includes a work requirement as a condition of eligibility for most enrollees (activities besides employment can include volunteer work, job search activities, training and education), which increases from 5 hours a week to 20 hours a week based on time enrolled. The proposal also requests to waive non-emergency medical transportation (NEMT) for the expansion population and eliminate retroactive coverage for most adults. Individuals with access to cost-effective ESI would be required to participate in ESI after the first year with Medicaid premium assistance. Most of the waiver provisions would apply to the adult expansion group, as well as to other non-disabled adult Medicaid enrollees.
In May 2017, the state proposed an amendment to the state’s MassHealth Section 1115 waiver, which is a waiver that affects all of the state’s Medicaid population. Massachusetts has implemented the ACA’s Medicaid expansion without a waiver, and while the state’s current waiver renewal is focused on restructuring the program’s delivery and payment system, the amendment proposes to add benefit changes for the adult expansion group to more closely mirror elements of private market coverage. In March the state sent a letter to CMS that in part requests flexibility in benefit design for the expansion population. Specifically, the state seeks to eliminate non-emergency medical transportation (NEMT) for individuals covered through the MassHealth CarePlus program that covers childless, non-pregnant and non-disabled adults ages 21-64. There would be an exception to provide NEMT to individuals participating in substance use disorder services. The state is also seeking to eliminate its current provisional eligibility rules, which allows an individual to be enrolled in MassHealth for a 90-day provisional eligibility period if eligibility cannot be verified. The state is requesting to discontinue provisional eligibility for individuals ages 21-64 with unverified income, with the exception of pregnant women, adults with incomes up to 200% FPL who are HIV-positive, and individuals with breast or cervical cancer with incomes up to 250% FPL.
Key Pending Waiver Requests for Non-Medicaid Expansion Eligibility Groups
- Seeking to add premiums:
- Maine ($14-$66/month)
- Wisconsin (Depending on income, none or $8/month)
- Seeking to add work requirements as a condition of eligibility:
- Maine (20 hours/week, averaged monthly)
- Wisconsin (80 hours/month)
- Seeking to add time limits on coverage:
- Maine (No more than 3 months in 36 month time period unless work requirements are met)
- Wisconsin (48 month time limit that can be extended if work requirements met; disallow reenrollment for 6 months)
- Seeking to add drug screening and testing: Wisconsin
In April 2017, Maine issued a draft waiver application to add certain eligibility and coverage requirements for its traditional adult Medicaid population (low-income parents, former foster care youth, individuals receiving Transitional Medical Assistance, and other individuals such as people with breast or cervical cancer or HIV or those receiving partial Medicaid benefits). Maine has not implemented the ACA’s Medicaid expansion, and some of the proposed concepts have not been approved for any Medicaid groups previously. First, the state proposes sliding scale premiums on most adults at all income levels, ranging from $14-$66/month. There would be a 90-day coverage lockout for individuals with incomes at or below 100% FPL who do not pay premiums after a grace period. The state is also proposing work requirements as a condition of eligibility for most enrollees, which could be met through employment or participation in approved job training for at least 20 hours/week (averaged monthly), being enrolled as a student at least half time, or completing a combination of employment and education. Individuals could also comply with the work requirement by participating in volunteer community service 24 hours a month, receiving unemployment benefits, or pursuing career planning/training in caregiver services and also providing these services for a non-dependent individual with a disability. Also, unless individuals meet the work requirements, coverage would be limited to no more than 3 months in 36 month time period. The state is also seeking to waive retroactive eligibility and apply a $5,000 asset test to coverage groups not currently subject to one.
While Wisconsin did not implement the ACA’s Medicaid expansion, the state does have an approved Section 1115 waiver from CMS that provides Medicaid coverage to all childless adults ages 19-64 with incomes up to 100% FPL (the state does not receive the ACA’s enhanced Medicaid match rate for this group). In April 2017, Wisconsin proposed an amendment to add in certain requirements for the population covered by the state’s existing waiver, and the final proposal was submitted in early June. The state modified the original proposal, which required premiums from individuals with income beginning at 21% FPL, and instead proposes that individuals with incomes between 51-100% FPL would have $8/month premiums and those at 50% FPL and below would not face premium requirements. The proposal includes a six-month lockout period for any enrollee who does not pay the premium amount, but third parties—such as hospitals, non-profit organizations, and employers—can pay premiums on behalf of enrollees. Individuals would be able to halve their required premium contributions by undergoing a health risk assessment and meeting certain requirements to address any identified health risks. The revised waiver amendment also imposes cost sharing of $8 for all emergency department visits, both emergency and non-emergency visits (the original proposal charged enrollees $25 for each visit after the first one).
Similar to Maine, Wisconsin is requesting the ability to implement measures that have never been approved by CMS, even for the Medicaid expansion population. Specifically, the state proposes to limit enrollment for most individuals ages 19 to 49 to a total of 48 months, after which they would be disenrolled and not allowed to reenroll for six months (unless they qualify for Medicaid under another eligibility category). However, certain individuals would be exempt and this time limit on enrollment could be modified if an individual meets certain work requirements. Specifically, each month that an enrollee works or participates in job training for at least 80 hours a month would not be applied to the 48-month enrollment limitation. The state is also seeking to have all Medicaid applicants and current enrollees participate in a yearly drug use screening. If these results indicate potential substance use the individual would be required to take a drug test (although individuals who indicate interest in seeking substance use disorder treatment during the screening can forgo the drug test and enter treatment). Individuals with positive drug test results for non-prescribed substances would need to participate in substance use disorder treatment. Individuals who do not meet these requirements would be ineligible for benefits until they comply. Additionally, the amendment requests the ability to use Medicaid funding for up to 90 days of residential substance use disorder treatment in institutions for mental disease. Finally, the state did not request for the current Medicaid match rate to increase for the population covered under the waiver to the ACA’s enhanced match rate for the expansion population.
As Congress continues its Affordable Care Act (ACA) repeal effort, and evolving replacement options are in the spotlight, NASHP continues to track issues that appear in replacement proposals and provide state perspectives. In past weeks we’ve looked through a state lens at high-risk pools and selling insurance across state lines. Today we tackle another element of possible ACA replacement proposals: health savings accounts (HSAs) and high-deductible health plans (HDHPs).
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.
State agencies across the country, from Medicaid to public health, to social services and corrections, are deeply engaged in multi-sector initiatives to reduce infant mortality. And for good reason — the United States ranks 25th among industrialized countries in infant mortality with a disproportionate number of being African Americans.
Despite the gravity of the problem, infant mortality is responsive to policy and prevention strategies. There are recognized risks including smoking, limited pre/interconception care, unsafe sleep practices, and pre-term birth as well as evidence-based interventions that require a multi-sector approach.
NASHP’s 29th Annual State Health Policy Conference a session on infant mortality featured a snapshot of three state approaches: Colorado, Indiana, and South Carolina. Each of these states has developed a public/private partnership committed to comprehensive strategies that address both medical and social factors related to infant mortality. Each has participated in HRSA’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN), identified state policy levers, and documented success stories.
Colorado’s Nurse-Family Partnership (NFP) has produced many positive outcomes. In fact, cumulative data as of December 31, 2015 shows that in 61 of the 64 counties served by the program, 90 percent of babies were born at a healthy weight and 91 percent of babies were born at full term . Because the NFP serves only first-time mothers, Health First Colorado, the state’s Medicaid program, offers Prenatal Plus to provide case management, nutrition counseling, and psychosocial services to all pregnant women at risk for negative maternal and infant health outcomes. These negative outcomes may be due to numerous lifestyle, behavioral, and non-medical factors that could affect pregnancy including a lost job or excessive debt, partner in jail, or prior low birth rate infant.
Health First Colorado has also devised strategies to ensure the accessibility of Long-Acting Reversible Contraception (LARC). The program pays full purchase price for LARC and a fee schedule rate for insertion at a physician’s office. Federally Qualified Health Centers (FQHC) are reimbursed through a Prospective Payment System (PPS) encounter rate based on full-costs for LARC devices and insertion. Health First Colorado received approval from CMS to pay free standing Rural Health Clinics (RHC) a separate payment for LARC devices because their PPS is not based on full cost methodology. The insertion of LARCs at an RHC is still paid at their PPS encounter rate. The state is also working with providers to reduce the rate of C-sections in low-risk, first time moms, and is considering options to provide physicians with information on their own C-section rates to encourage quality improvement.
Indiana’s Perinatal Quality Improvement Collaborative recognizes the value of multi-sector partnerships and data-driven evidence-based strategies. Through a public/private partnership, the state Medicaid agency was able to establish a policy for nonpayment for early elective delivery. A Management and Performance Hub collects information from a variety of state data sources, including Medicaid, the Department of Corrections, and multiple State Department of Health sources including HIV/STD and Maternal and Child Health. This collection of data sources has assisted the state in identifying three distinct high-risk subpopulations that account for only 1.6 percent of the sample population but nearly 50 percent of infant deaths. This information has enabled the state to target interventions. These high-risk subpopulations include low birthweight, preterm birth, and limited access to prenatal care, the most significant factor identified.
As a demonstration of state commitment, the Safety PIN (Protecting Indiana’s Newborns) grant program enacted by the Indiana Legislature in 2015 appropriates $13.5 million to reduce infant mortality: $2.5 million will support development of a two-way app for pregnant women to encourage better prenatal care and $11 million will be distributed through a competitive grant program to nonprofit organizations, local health departments, and health care entities for innovative approaches to address infant mortality.
South Carolina’s Birth Outcomes Initiative is a public/private partnership of payers, providers, and other partners. Among its achievements are a dramatic reduction in early elective deliveries partly as a result of Medicaid nonpayment policies. Additionally through the initiative the state saw a 110 percent increase in LARC insertions in the past two years, and a decrease in infant mortality of 23 percent among non-white populations, and a 9 percent decrease overall.
South Carolina is the first state to initiate a pay for success model for birth outcomes, developed through a 1915(b) waiver in partnership with its NFP and the Children’s Trust. The program will enroll approximately 4,000 additional mothers in NFP evidence-based home visiting services over a four-year period. The waiver allows for “non-statewideness,” enabling the program to focus on communities most at risk. Through a combination of philanthropic support and Medicaid funding, the program provides upfront capital to expand services. Full success payments begin only if an independent randomized controlled trial finds that the NFP can meet the outcome targets: a reduction in preterm births by 15 percent, reduction in child injuries by 26 percent, and an increase in birth spacing by 20 percent. Other success payments will be made only if at least 65 percent of those enrolled reside within a set of targeted rural and underserved communities.
These states provide a snapshot of policy and financing levers that, as part of a comprehensive strategy, can make an impact on infant mortality. Questions remain about how best to capitalize on the momentum and develop complementary policy and programmatic approaches. For instance, what approaches can reduce the significant disparities as evidenced by an African American infant mortality rate that is two to three times higher than for the white population in each of the three states profiled? What are the most effective strategies for engaging African American communities in efforts to develop patient- and community-centered approaches? Some communities may be distrustful of LARC interventions unless they know the state policies for removal of the devices. In two of the three states profiled, Medicaid policies place limits on when removal is covered. In South Carolina they are covered when medically indicated and in Colorado coverage is provided when the medical provider and client are currently enrolled in the Medicaid program at the time of the LARC removal. What interventions are most effective in addressing social factors that contribute to infant mortality? Lessons will continue to emerge as all states continue to innovate and wrestle with these questions.
To help better prevent and control costly conditions such as chronic diseases, and to break the cycle of poor health, states are experimenting with mechanisms to incentivize healthy behaviors and personal responsibility for wellness. This past October, as part of the 29th Annual State Health Policy Conference in Pittsburgh, PA, leaders from Connecticut, Idaho, and Indiana shared their experiences along with the unique approaches their states are taking to address this issue. As part of the session “Incentivizing Health Behaviors and Personal Responsibility: What Have We Learned?” the leaders addressed how these approaches align with their states’ priorities and goals. Connecticut offered cash incentives to Medicaid beneficiaries attempting to quit smoking, while both Idaho and Indiana reduced cost sharing in public health insurance programs if beneficiaries perform certain healthy behaviors.
Among the three states discussed here, Connecticut’s incentive program has the narrowest scope. The state received a five-year federal Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) grant to test the effectiveness of financial incentives in encouraging tobacco cessation among adult Medicaid beneficiaries. Connecticut’s program, Rewards to Quit (R2Q), began enrollment in April 2013 and divided enrollees into control and intervention groups. Those in the intervention group who utilized smoking cessation services or quit could receive money through a debit card. As of April 2016, 3,692 participants were enrolled in the program, compared to the enrollment goal of 6,210. Connecticut’s presentation slides at the NASHP Conference offer more details on the state’s MIPCD program.
Unlike Connecticut and Indiana, Idaho has not expanded Medicaid, and the scope and target population of Idaho’s program is more narrow than Indiana’s, The wellness arm of Idaho’s Preventive Health Assistance (PHA) program, introduced in 2007 as an amendment to the state’s Children’s Health Insurance Program (CHIP), has incentivized child wellness visits and vaccinations by reducing premiums for families whose children receive these services. In 2016, 18,809 out of 20,021 (93.9 percent) children in Idaho’s CHIP population have premiums, the remaining were exempted from paying premiums. Approximately 66 percent of these children’s families have earned premium reductions as a result of wellness visits. Prior to the implementation of PHA, only 40 percent of these children were up-to-date with their wellness checks and immunizations. Please see Idaho’s presentation slides at the NASHP Conference for more information.
Indiana’s approach to incentivizing personal responsibility for wellness is similar to Idaho’s. Since 2008, Indiana has offered low-income individuals a high-deductible health plan paired with a health savings-like account called Healthy Indiana Plan (HIP). In 2015, the state expanded Medicaid under an § 1115 demonstration, and “HIP 2.0” became available to all non-disabled Indiana residents ages 19-64 with income up to 138 percent of the federal poverty level (FPL), including those that were previously eligible for Medicaid. As of November 2016, there were almost 400,000 enrollees. HIP members can make monthly contributions to their POWER accounts, a feature of HIP that is similar to a health savings account (HSA). Members with income under the FPL who do not make POWER account contributions are transferred to a more limited plan without dental and vision coverage and are subject to co-payments for services. All CDC-recommended preventive services are available to all HIP members at no cost. HIP incentivizes its members to utilize prevention services by allowing unspent POWER account contributions to roll over to the next year to reduce future account contributions if members receive required preventive services. According to the state, HIP members who contribute to their POWER accounts are more likely to obtain preventive care (64 percent) than members who do not contribute (45 percent). For more information, please refer to Indiana’s slides presented at the NASHP Conference.
Evidence-based chronic disease prevention programs have a potential to reduce health care costs, and the results of these relatively new initiatives to incentivize healthy behaviors and personal responsibility will provide more information to policymakers. Historically, designing effective incentive programs has been a challenge. Previous research suggests that incentives are more effective in the short-term than in the long-term. This raises several questions that states and other stakeholders should consider: 1) Can incentives promote healthy behaviors in the long-term that are substantial to improve health outcomes? 2) Are the programs cost effective? 3) How can states develop multi-sector strategies that align incentive programs with strategies that address social determinants that impose barriers to individuals trying to adopt healthy behaviors? 4) How might states finance this alignment? Although these questions remain, states are natural laboratories to test and evaluate incentive strategies that have potential to improve population health, experience of care, and control.
For additional information on states’ efforts to incentivize healthy behaviors in Medicaid, please go to this MACPAC Issue Brief.
 To learn about HIP prior to Medicaid expansion, please visit this KFF Fact Sheet.
 The Lewin Group, Inc. Healthy Indiana Plan 2.0: Interim Evaluation Report.
 Blumenthal et al, 2013