State-based marketplaces (SBMs) give states more control over their local health insurance markets and consistently outperform states that use the federal marketplace with higher enrollment, more insurance plan choices for consumers, lower premium rate hikes, and a younger consumer base. These accomplishments are especially notable given recent federal policy actions that have unsettled insurance markets and contributed to a national rise in uninsured rates.
SBMs’ success coupled with the evolution of new and lower-cost marketplace management technology is prompting a growing number of states to convert to the SBM model. Nevada recently decided that converting from the federal platform to an SBM offered the state more control to provide insurance plans to consumers at a lower administrative cost and recently New Jersey and Pennsylvania have gone even further, enacting laws to move off the federal marketplace to create their own SBMs to be operational by January 2021.
Both states will finance their programs by converting the current federal assessment on health plans to a state-administered fee. New Jersey Gov. Phil Murphy signed A5499, which empowers the state’s Department of Banking and Insurance to set up the SBM within the agency and to coordinate with Medicaid to assure integrated eligibility for both programs. The law also creates an advisory committee to guide the work. New Jersey’s creation of its own marketplace follows successful efforts last year to enact an individual mandate that requires insurance coverage and the creation of a reinsurance program to help lower premium costs by providing funds to offset the impact of high-cost enrollees.
In Pennsylvania, Gov. Tom Wolf last week signed HB 3, which enjoyed bipartisan support, that creates a new, quasi-independent state agency to administer the SBM. Pennsylvania expects its state-based exchange will save the state money in the long term. The savings will be used to fund a portion of a state reinsurance program, which could reduce insurance premiums by up to 10 percent. The state expects to seek a Section 1332 waiver to enable it to develop its reinsurance program.
As a result of these two states’ actions, 20 states will soon operate an SBM or an SBM that utilizes the federal platform. Learn more about how states can create SBMs from marketplace leaders here.
NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.
Substance use disorder (SUD), including opioid use disorder (OUD), is prevalent among pregnant and parenting women, and these women have unique and often un-met treatment needs. Despite significant efforts, states report that access to treatment continues to lag for this population. In 2014, half of pregnant women with OUD who were enrolled in publicly-funded treatment programs received medication-assisted treatment (MAT) – considered the standard of care for people with OUD. New mothers are also at increased risk of relapse and overdose during the postpartum period.
Recognizing the needs of this population, Congress recently passed the SUPPORT for Patients and Communities Act, which orders a Government Accountability Office study into the coverage gaps that persist for pregnant and postpartum women with SUD who were eligible for Medicaid during pregnancy. And last week, the federal Center for Medicare & Medicaid Innovation announced the Maternal Opioid Misuse Model, which will offer cooperative agreements to up to 12 states to transform their delivery systems for pregnant and postpartum women with OUD and reduce fragmentation in delivery of care.
As SUD impacts mothers, it also affects their children. Between 2000 and 2012, rates of neonatal abstinence syndrome (NAS), caused by opioid exposure during pregnancy, rose five-fold, accounting for $462 million in Medicaid hospital costs in 2014. Exposure to other substances, such as alcohol, can also affect child development and parental substance use is linked to increased risk of child welfare involvement and childhood trauma.
A new National Academy for State Health Policy (NASHP) report, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder, supported by the Health Resources and Services Administration Office of Women’s Health, identifies promising strategies from Colorado, Pennsylvania, and Texas to support pregnant and parenting women with SUD. These states:
- Support access and coverage through early identification of substance misuse by expanding postpartum coverage for SUD treatment, and by facilitating transitions between care settings. In Texas, a state that has not expanded Medicaid, women may become ineligible for Medicaid coverage 60 days after giving birth. As a result, they face challenges continuing SUD treatment beyond 60 days postpartum. To address this issue, Texas expanded state-funded SUD treatment slots for postpartum women. Under this initiative, when a woman’s Medicaid coverage ends after giving birth, she can seamlessly transition to a treatment slot funded by state general revenue without being on a waiting list, and experience no change or disruption in her providers or services.
- Implement innovative care delivery models that consider the unique needs of women and families, such as integrating reproductive health care and SUD treatment, family-centered care models, and supports for social determinants of health. For example, Pennsylvania offers a Centers of Excellence (COE) program, funded by Medicaid and state general revenue, which provides coordinated and team-based care to individuals with OUD. Six COEs focus on meeting the unique needs of pregnant and postpartum women. These COEs coordinate services including SUD treatment, obstetric and postpartum care, and services that address social determinants of health, such as housing and transportation.
- Promote cross-system financing and collaboration to develop alignment across policies and programs and to leverage multiple federal and state funding streams. For example, Colorado’s Special Connections program offers comprehensive and coordinated SUD treatment services for Medicaid enrollees who are pregnant and the services continue up to 12 months postpartum. The program is administered through a partnership between the state’s Department of Health Care Policy and Financing and Office of Behavioral Health. The program weaves together funding from Medicaid (authorized under the Medicaid state plan and a 1915(b) waiver), the federal Substance Abuse Prevention and Treatment Block Grant, and state general funds.
To learn more:
- Read NASHP’s new issue brief, State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder.
- Listen to a recording from an Oct. 24, 2018 webinar that explores how Colorado supports pregnant and parenting women with SUD.
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
- Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
The opioid epidemic has heightened states’ efforts to prevent and treat of substance use disorder (SUD) in pregnant and parenting women. The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration, interviewed Colorado, Pennsylvania, and Texas officials about the unique interagency approaches they are using to promote recovery for this population. This new report explores:
- State coverage, care delivery, and financing strategies to support pregnant and parenting women with SUD;
- Available state and federal funding sources for these initiatives; and
- Key considerations for states working to promote recovery.
- Download webinar slides and listen to the webinar that explored how Colorado supports pregnant and parenting women with SUD. The speakers were:
- Amy Cooper, Women’s Services Coordinator, Office of Behavioral Health, Colorado Department of Human Services;
- Susanna Snyder, Maternal Child Health Policy Specialist, Health Programs Office, Colorado Department of Health Care Policy and Financing; and
- Dr. Kaylin Klie, Physician, Denver Health; Assistant Professor, University of Colorado Department of Family Medicine
- Read NASHP’s issue brief State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis, and listen to a NASHP webinar on the topic.
- Read presentations from NASHP’s preconference Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
In late March, Jessica Altman became Pennsylvania’s insurance commissioner, responsible for protecting consumers in the fifth-largest insurance market in the United States and the 14th-largest in the world.
Altman, who is vice chair of the National Academy for State Health Policy’s (NASHP) Health Care Access and Finance Steering Committee, helped implement the Affordable Care Act (ACA) when she worked at the Department of Health and Human Services’ Center for Consumer Information and Insurance Oversight. She joined Pennsylvania’s Insurance Department in 2015 as its chief of staff and served as acting commissioner since August of 2017.
Altman talked to NASHP recently about the evolving role of health insurance coverage in state and national politics, and how her own career trajectory has followed the evolution of health insurance as the country’s critical health care issue.
Q: How did you come to insurance regulation?
Health insurance is a critical part of the ACA, which fundamentally changed the way the health delivery system works in our country. Working on the ACA demonstrated to me the impact that government can have and the unique and critical role that insurance plays in each of our lives. No one likes to think about insurance – it is strange to invest time and money in something you hope you will never need – but it’s so important for the critical times in people’s lives, whether you need your health insurance for an illness, your car insurance after an accident, or your homeowners insurance following a fire. I have always wanted to be in public service, and when I moved from the federal government to the state level, what especially appealed to me was the consumer protection aspect of this job and the ability to work more directly with consumers and address the issues most important to them.
Q: How has the ACA worked in Pennsylvania?
In many ways, the ACA has been a huge success in Pennsylvania. Our uninsured rate is at an all-time low, and I believe there is a sense of financial security and access to coverage that did not exist before the ACA. When engaging in various communities, I have seen people cry tears of joy because they were able to find better health insurance coverage under the ACA today for thousands of dollars less than ever before. Pennsylvania’s exchange is also among the nation’s healthiest, with five major health insurers insuring about 400,000 residents.
Implementation of such transformative reform has not come without its challenges though, and state regulators are constantly responding to changes directed by the federal government, while implementing policies that we believe will mitigate any potential harm and be in the best interest of the people we serve. One example of our responsiveness is how states around the country recently dealt with President Trump’s decision to stop making payments to fund the cost-sharing reduction program. States found a way (the so-called “silver loading” strategy) to account for these costs by building them into health insurance rates, while actually helping consumers better afford more generous coverage because of the way the premium tax credit structure works.
Q: Does it surprise you that the ACA has had such a profound effect on the country’s health policy dialogue?
Yes and no. I am surprised by the magnitude of the ACA’s impact considering that much of the act focuses on reforming the individual and small group market, while leaving many areas of the system, and in fact the areas where the majority of Americans receive coverage, employer-sponsored coverage and Medicare, relatively unchanged. I think many people have a perception that the ACA reforms are broader than reality. I see this every year when we go through the rate review process, and I hear from many consumers their concerns about requested increases, only to find that most of them will not be impacted because they do not rely on the individual market for coverage. The individual market serves only about 5 percent of Pennsylvanians, and while it is an important and challenging market that we will continue to work to improve, most people are served by other areas of our system that are not experiencing the same volatility that the individual market is today.
Simultaneously, I am not surprised by the profound impact of the ACA because the act represents a fundamental shift in how our government approaches health care. It was a huge step in ensuring health care coverage is a right and not a privilege in this country. There is no doubt that the shift has come with some growing pains, but I believe it has also demonstrated that health insurance is a fundamental right and need, and government should play a role in it.
Q: Did you know how controversial the ACA would be years after its inception?
I was among the first hires to implement the ACA and we had only a few months to make decisions and implement the early regulations while scrambling to set up an organizational structure. When you’re in that environment, you don’t have time to think about how important the work is, but I did have moments when I thought about how friends and family members with pre-existing conditions would finally, for the first time in their lives, get affordable and high-quality insurance. Because of that, I always believed that the ACA would gain acceptance over time. There are many reasons why the ACA remains controversial today, from pieces of the law itself, to changes made to it over time, to just plain politics, but I remain hopeful that we can work together to embrace what is so good about the ACA while looking for solutions to what may not be working.
Q: Is having the country’s persistent debate about ACA important, despite its contentiousness?
Having a national dialogue about our health care system, who that system is working for and who it is failing, is unquestionably valuable. What is important is under the ACA, at the end of the day, is that no one must worry if they can get health insurance if they have a devastating need; it is now there for everyone who needs it. As changes have been discussed and made, I think the dialogue has instilled in people an appreciation for the necessity of coverage from a financial stability perspective, which is why the ACA has made such a difference. My hope is that this dialogue will help move us forward. We need to fix what needs to be fixed, and focus on the many other problems our health care system has, namely cost. The ACA gave us the assurance of coverage, but we have a long way to go to get to the assurance of truly affordable care. Let’s talk about that.
Q: Has it been hard to see the ACA dismantled by the Administration?
It has been incredibly disappointing. What was proposed in the ACA stabilization package (reinstatement of cost-sharing reduction subsidies for moderate- and middle-income residents and creation of reinsurance to help high-risk consumers) would have been a measurable benefit to state insurance markets around the country. I worry about the subset of the population [about 1 to 2 percent of Pennsylvanians] who depend on the individual markets and are not eligible for financial assistance. They’re not protected from decisions that have been made in Washington or from future decisions that may weaken the ACA and increase premium prices. But, I always have hope that those of us who have the privilege of serving the public will do whatever we can to protect insurance coverage and have a positive impact.
Q: What will be the impact of the “thin,” short-term policies that the Administration is proposing on state ACA marketplaces?
There are a number of different plans being talked about that don’t guarantee the comprehensive coverage that ACA provides, for example, coverage of essential health benefits, no discrimination against those with preexisting conditions, no caps on insurance limits, and the right to appeal if coverage is denied. I am working to be a source of accurate information in my state for the public, no matter what insurance choices they ultimately have. We will use the state laws we have to educate and protect consumers.
All insurance regulators around the country are concerned about the overall impact that these short-term policies will have on states’ individual markets if they are able to draw healthier people out of those major markets and drive up costs. Here in Pennsylvania, we don’t have laws or regulations that expressly address these short-term plans, but that will not prevent us from monitoring their impact on the market and looking for ways to mitigate negative impacts on those we serve. In particular, we have already revoked a number of licenses of insurance professionals who misrepresented these plans to consumers and will continue to ensure no consumer is misled about the coverage these plans provide – or do not provide.
Q: Do you have tools and responsibilities you didn’t expect to have as a commissioner given the dramatic changes in the national health insurance landscape?
I came into the job when the ACA already existed, but I know other regulators around the country have seen a huge transition. Insurance has historically, and by law, been a purely state-regulated industry. The ACA introduced a dual role, where the federal government has become a secondary regulator in addition to state regulators, and that has definitely been a challenge. Grappling with that will continue to be a challenge, and not limited to just health insurance – it’s true of other areas of insurance where the federal government plays a significant role, like flood insurance. State regulators are problem solvers and our job is to solve the problems facing our consumers. Because of this dual regulatory framework, we need the federal government to be a partner in solving those problems. Unfortunately, that is not what is happening today.
Q: How hard is it to be an insurance commissioner in this era when you need to quickly respond to sudden federal changes to the ACA coverage?
Insurance regulators have always had to mobilize quickly and respond to emergencies such as floods, fires, or earthquakes by getting on the ground and helping the consumers we are here to protect. However, we would much rather focus on those natural disasters than disasters coming due to eleventh-hour and late-breaking decisions from the federal government.
Historically, before the ACA, we only had state-regulated insurance markets, but with these decisions coming from the federal level where sometimes the only role we are able to play is to mitigate a decision that we were not part of making, it’s very frustrating. But, it is rewarding is to be on the ground and indeed try to mitigate those situations.
Q: Do you see your job changing in the months and years ahead?
We have a lot of work to do to monitor numerous things that are coming our way to shape our markets, for example, the potential proliferation of association or short-term health insurance plans. In addition to consumer protection, my department’s role is to serve as a trustworthy source of information, and we’ve been doing much more to be proactive and inform consumers about these issues. When the federal government curtailed insurance market sign-ups and enrollment time, we launched our own coalition of elected officials, insurers, citizen groups, and health care providers to make clear to consumers what was happening, and what the time limit for marketplace sign-up was. I see that effort continuing.
Q: How does being part of NASHP help you in your job?
I’m a big believer in states learning from each other, from what they have done and brainstorming what we can do. It is invaluable to have credible data and state leaders from around the country get together to talk about different approaches and experiences and do it in a nonpartisan and slightly wonky way. That’s incredibly valuable for us who take the time to take advantage of it.
We insurance regulators have the National Association of Insurance Commissioners that plays an irreplaceable role in convening state regulators and facilitating thought and action on national issues facing the insurance industry and the regulatory community, but to have the additional opportunity to meet and talk with state leaders from departments of human services, Medicaid, and other health care systems who have different perspectives allows us to better engage in a comprehensive discussion of state health care policy.
Q: Your governor is proposing integrating the Department of Human Services with the Department of Health to improve efficiency and innovation. Where does your department fit into improving overall improvement of health care delivery?
I am privileged to serve alongside a group of cabinet members who lead Pennsylvania’s health and human services agencies, including my predecessor Teresa Miller, who value collaboration and are committed to taking a unified and coordinated approach to Pennsylvania’s most pressing health care issues. As we look to combat the opioid crisis, to find value in our health care system, to improve health in our rural communities, and deal with the many other issues all state health officials are facing, having the level of communication and partnership that we do is a major asset. We all have different levers and priorities and strategies for our own agencies or constituencies, but doing that in a way that we are all moving in the same direction and with the same ultimate goals in mind is going to mean we get there faster and, at the end of the day, hopefully achieve better outcomes.
Responding to rapidly rising drug costs, 30 states across the country have drafted more than 60 drug price transparency bills designed to:
- Identify the costs that contribute to drug manufacturer expenses and list prices
- And unveil the often opaque business practices of pharmacy benefit managers (PBMs).
In addition to promoting pricing transparency, as of early August state legislators had also introduced more than 100 bills addressing different aspects of rising drug costs.
States are large purchasers of prescription drugs for a number of programs and agencies, such as Medicaid, prisons, and state employee benefits. Escalating drug prices have put pressure on states to create legislation to improve the sustainability of their budgets and ensure health care access for their residents.
Some of the more ambitious proposed legislation requires manufacturers to justify prices, particularly for new drugs or for large year-after-year increases for older drugs that strain state budgets. Other states plan to use their authority to take action under long-standing “unfair business practices” laws. By increasing the transparency of prescription drug prices, lawmakers hope to be better equipped to manage costs and lower the burden on taxpayers and health care consumers. Here are brief highlights of state transparency proposals.
Vermont: Policy Innovation with Transparency
Last year, Vermont passed Act 165, the nation’s first drug price transparency law, which has spawned similar legislation across the country. Act 165 requires the Green Mountain Care Board to identify “drugs on which the state spends significant health care dollars and for which the wholesale acquisition price has increased by 50 percent or more over the past five years or by 15 percent or more over the past 12 months.”
The board reports to the state’s Attorney General (AG), who may require manufacturers to submit information and documentation justifying the price. In assessing the impact of the legislation, observers have noted that the law addresses only Medicaid expenditures and does not affect other large purchasers. Also, manufacturer data the law required was not highly detailed, which has made it difficult to gauge if the prices and increases are justified or not.
Nevada: Increased Transparency for Nonprofits and Pharmacy Benefit Managers (PBMs)
Nevada’s Governor recently signed into law Chapter 592, which requires price transparency by manufacturers and revenue transparency from nonprofit patient advocacy organizations. It also sets new standards for PBM business practices. Patient advocacy organizations are now required to report contributions and benefits received from drug manufacturers, insurers and PBMs, or the trade and advocacy groups for such entities. Nevada-based PBMs now have a fiduciary responsibility to their contracted insurers and must disclose all rebates they receive from manufacturers. PBMs are also prohibited from certain anti-competitive business practices, such as gag clauses, that prevent pharmacists from discussing drug prices with their patients.
Maryland: Protecting Consumers from Price Gouging
Earlier this year, Maryland passed HB 631, which seeks to protect payers from “unconscionable” drug prices. The law applies only to off-patent and generic drugs, and it authorizes the state’s AG to take legal action if the AG’s office deems a drug price unconscionable. The courts may impose penalties on the manufacturer if it finds the manufacturer has violated the law.
Slated to take effect Oct. 1, 2017, the bill caused the generic drug trade association to sue in an effort to block the bill. While states await the court’s decision, other states such as New York have already introduced similar legislation.
California: Price Transparency for Manufacturers and Cost Transparency for Payers
California’s transparency proposal, SB 17, requires a 60-day notification of price increases over a specified pricing threshold and mandates that health plans report the percentage of premiums spent on prescription drugs. The bill is being closely watched because it is facing fierce industry opposition but has continued to move forward. Update: On Sept. 11, 2017, the California General Assembly overwhelmingly approved SB and it is expected to be signed into law.
Pennsylvania: Transparency and Alternative Payment Models
Some states have proposed legislation to use information obtained from transparency directives to formulate alternative payment models for prescription drugs. Pennsylvania’s HB 1464 proposes to document a wide array of cost-contributing factors that affect a drug’s wholesale acquisition cost. The bill also studies additional costs incurred from expensive medical interventions or hospitalizations that result because of patients’ inability to afford and maintain access to prescription drugs.
While transparency will not bring all the change that is needed, many agree it provides a necessary foundation on which to build future legislation that will have greater impact on controlling drug costs.
Another Model to Lower Costs: Determining “Excessive Costs” and Working with Payers
Four states recently proposed legislation (MA SB 652, NJ S 3088, NY A 5733, OR HB 2387) that attempted to determine when drug prices create “excessive costs.” The bills generally establish a dedicated commission or board with the authority to work on behalf of a state’s best interest in evaluating and making recommendations about prescription drug prices based on data reported by drug manufacturers.
Oregon HB 2387, which attempted to protect both consumers and payors (who provide the insurance coverage), failed to pass, but it included some novel provisions. The bill proposed a cap on patient costs, which required private or public plans to pay the remainder. To offset this cost, the manufacturer would reimburse those purchasers when costs exceeded specified price thresholds. With a cap on patient costs and only limited reimbursement from manufacturers for any “excess” plan costs resulting from the cap, opponents of the bill were concerned that it would lead to cost shifting onto public and private plans, ultimately increasing the out-of-pocket costs for some consumers. NASHP recognizes these challenges and has developed a Rate Setting Model legislation to address these and other legal and regulatory concerns.
Working to Coordinate and Maximize State Efforts
How effective these early bills will be remains to be seen, but one fact is certain—state legislatures want solutions to the high costs imposed by current drug prices. NASHP’s Center for State Rx Drug Pricing will continue to track states’ legislative efforts and its Rx Cost Workgroup will produce more state resources. For more information read: States and the Rising Cost of Pharmaceuticals: A Call to Action.
The National Academy for State Health Policy (NASHP) in collaboration with Covered California today released a new report, Barely Covered: Initial Analysis of Coverage and Affordability Impacts to Consumers Under the Proposed Better Care Reconciliation Act, and 50-state interactive tool that compare the costs and comprehensiveness of coverage under the Better Care Reconciliation Act (BCRA) and the Affordable Care Act (ACA). This initial assessment of BCRA, which compares the benefits, deductibles, and maximum out-of-pocket expenses in California, Ohio, and Pennsylvania, showed significant reductions in benchmark benefits and tax credit support particularly for lower-income and older individuals.
Currently, the ACA uses the silver level plan as its benchmark. The silver level plan on average pays 70 percent of the consumer’s health care costs. Under BCRA the benchmark plan will be the bronze level, which covers only 58 percent of costs. BCRA also allows plans to charge older consumers five times more than younger ones, limits who is eligible for subsidies, allows states to waive out of providing Essential Health Benefits as part of coverage plans, and in two years repeals cost-sharing reductions that protect lower-income consumers from high out-of-pocket costs. A key difference in plans highlighted by the report is that consumer cost sharing will be higher and more services will be subject to cost sharing
“Seventy percent of consumers currently in the marketplace are covered by silver plans;” said Trish Riley, Executive Director of NASHP. “Under the BCRA, many who like that coverage and want to keep it will be hard-pressed to afford the costs.”
The report shows the differential in cost and coverage for benchmark plans under both ACA and BRCA by comparing estimated annual consumer premiums in both a high- and low-cost county in each state. For example a 60-year-old in Muskingum County Ohio, a high-cost county, earning $50,000 annually would pay $5,100 under the ACA, that cost would jump to $16,130 under the BCRA. Comparatively, a 27-year-old in the same county with the same income would see premium costs drop from $4,640 under the ACA to $4,280 under BCRA (see 50 state interactive tool).
“These potential impacts should be carefully evaluated to determine their likely impact on the stability and long-term viability of the individual insurance market.” Added Riley.
The report noted that Stability funds included in the BCRA could offset some costs but would require significant state outlays in future years. States may need to choose between strategies to moderate high prices or to backfill the loss of federal funds to protect consumers from high out-of-pocket costs.
*Covered California is the largest State-based Marketplace in the country
The American Health Care Act, which proposes to repeal and replace the Affordable Care Act (ACA), would dismantle the Prevention and Public Health Fund (PPHF). States received over $625 million from the PPHF in fiscal year 2016,[i] and stand to lose more than $3 billion over five years if it is repealed.[ii] The bill would repeal all new appropriations for the PPHF starting in fiscal year 2019, and rescind any funds left over at the end of 2018.
States could lose $160 million per year from the Preventive Health and Health Services (PHHS) Block Grant, which has been entirely funded by the PPHF since 2014.[iii] The Block Grant awards funds to all 50 states and the District of Columbia to support state public health infrastructure, respond to emerging public health issues, and address the health priorities of states in “innovative and locally defined ways.” Although the Block Grant existed prior to the creation of the PPHF, it now relies wholly on it for funding.
Eliminating the PPHF could also hamper state efforts to respond to the opioid crisis. As states work to respond to increasing numbers of deaths from drug overdoses, state public health departments have stepped up prescription drug monitoring programs and other interventions with the support of the Centers for Disease Control and Prevention (CDC). Since 2010, Pennsylvania has received more than $83 million from the PPHF to support opioid prescription monitoring, along with vaccine programs, cancer screenings, infectious disease detection and response, and chronic disease prevention.
- Pennsylvania Secretary of Health Dr. Karen Murphy said, “Repealing the Prevention and Public Health Fund would resonate beyond the federal level and hit state and local health departments hard…The loss of this funding in the coming years arrives at a time when major health threats, like infectious diseases and the opioid epidemic, are on the rise. The PPHF is vital to help protect the health of the nearly 13 million people who call Pennsylvania home.”
States also rely on the PPHF to help them keep children and families healthy. Louisiana depends on $9 million annually from the PPHF to support programs such as lead testing for children and home visits for low-income pregnant women and new mothers, which reduce premature births, according to Louisiana Secretary of Health Dr. Rebekah Gee. In 2016, $17 million in PPHF funding helped states reduce childhood lead exposures and conduct blood-lead testing and surveillance. Those funds helped states respond to disease outbreaks such as the flu and measles, as well as bolster their immunization infrastructure.
Virginia received just under $10 million in 2016 from the PPHF, including funds to fight heart disease and stroke, immunize children, and reduce health disparities and premature deaths, according to one report. Virginia State Health Commissioner Dr. Marissa J. Levine was quoted as saying that if all of ACA repeal goes forward, “we could pretty rapidly lose about $27 million like that.” Over $324 million in the CDC immunization funds that support states would be jeopardized by a dismantling of the PPHF.
States could also lose $40 million from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement if the PPHF is abolished by the American Health Care Act. The ELC also gave cities and states an additional $60 million in July 2016 to fight Zika. The ELC, which receives over 40 percent of its funding from the PPHF, enhances state laboratory and epidemiological capacity and supports state health information technology infrastructure. The ELC also funds state efforts to address tick-borne diseases, influenza, drug-resistant infections, foodborne illness, and hospital-acquired infections, among others. It also helped pay for more than 1,000 jobs in state and local health departments. [iv]
What can we learn from states?
Recent state experience illustrates what is at stake in conversations about reducing federal support for state public health infrastructure. The 2016 Zika crisis stretched to capacity the existing disease surveillance and response infrastructure of some states. Florida relied on additional support from the CDC to speed up the processing of laboratory testing for the Zika virus by providing thousands of test kits and seven laboratory technicians to help process them. Texas received scientific expertise, cross-state coordination, and a $5 million grant from the CDC’s supplemental Zika funding approved by Congress to combat the disease. The state also received Zika response funding from the PPHF.
Even when states are meticulously efficient stewards of resources, the ability of state public health agencies to respond to crises may be compromised if the American Health Care Act takes away the PPHF funding from states and the CDC. Responding to outbreaks and new infectious diseases is a matter of fiscal as well as public health: Infectious diseases cost the U. S. more than $120 billion per year, yet funding for core public health preparedness and response has been cut by more than one-third in the last 10 years.[v]
Questions for policymakers
- What public health functions will states have to cut or scale back if the PPHF is eliminated? Would state cuts lead to a failure to reduce drug overdoses, injuries, or infectious, chronic, and/or vaccine-preventable diseases?
- Would state cuts to public health programs lead to greater expenditures by Medicaid, criminal justice, or other state agencies? If so, how can those expenditures be quantified and budgeted for?
- Will the PHHS Block Grant be discontinued if the PPHF goes away? Or will the Block Grant be continued with a different federal funding source? If so, what will be the source of funding? How would funding levels change?
- Will states be able to afford to use general fund dollars to make up for the loss of federal prevention funding? What other state funding will be cut to make up the difference?
The ACA created the PPHF to fund both new prevention programs as well as programs that predated it. As the House bill to repeal and replace the ACA and eliminate the PPHF moves through Congress, policymakers should reflect on the impact of its repeal on states. There is much to learn from states stretched thin by responding to infectious diseases and the opioid crisis at the same time as battling preventable diseases and chronic conditions. We see what happens when under-resourced states are called upon to respond to extraordinary events; what will we see if robust federal help is no longer available to states? What do policymakers need to protect states’ ability to safeguard the health of their residents?
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.
[i] U. S. Centers for Disease Control and Prevention (CDC), “Accomplishing CDC’s Mission with Investments from the Prevention & Public Health Fund, FY 2010-FY 2016,” https://www.cdc.gov/funding/documents/cdc-pphf-funding-impact.pdf
[ii] Trust for America’s Health (TFAH), “Special Analysis: Prevention and Public Health Fund Federal & State Allocations,” January 2017, https://tfah.org/reports/prevention-fund-state-facts-2017/
High-profile diseases such as Ebola and Zika grab headlines, but state health policymakers know that emergency preparedness begins long before the first news stories—or symptoms—appear. Preparedness and response often includes cross-sector work that addresses the intersections between public health infectious disease strategy and state Medicaid and emergency management policies. At the nexus of federal policy and local concern, state health policymakers are well-positioned to lead prior to, and during, health emergencies.
The recently announced Centers for Medicare & Medicaid Services funding opportunity to support Zika prevention and treatment activities could help state health departments invest in public health infrastructure that would position them well to respond to the next crisis when it occurs.
As concern about Zika virus continued deep into autumn, state leaders from Texas, Pennsylvania, and Florida spoke at the 2016 NASHP State Health Policy Conference about their strategies for preparing for and responding to public health emergencies and infectious disease outbreaks. They shared tips for navigating messaging challenges, especially when communicating with a restive and worried public. Panelists also noted the importance of robust public health infrastructure and cross-agency collaboration in developing and refining preparedness and outbreak investigation strategies.
- Communicate clearly, consistently, and credibly.
According to state leaders, communicating with the public and sharing facts and techniques for minimizing risk is central to preparing for and addressing outbreaks and emergencies. Texas honed its disease investigation and response practices in the crucible of the Ebola crisis. The first patient to be diagnosed in the U. S. with Ebola came to a Dallas hospital in September 2014, according to the CDC. Shortly thereafter, a healthcare worker who cared for the patient contracted Ebola. The state’s experience with this very high-profile situation informed its strategy for responding to Zika and other infectious diseases. The public health risks of confusion and panic, and the importance of having clear lines of communication and a flow of accurate, consistent, and timely information to the public and decision-makers were key lessons Texas learned in the aftermath of Ebola. Texas put this knowledge into practice in its Zika response by continually publishing health alerts and regular updates on Zika case counts.
Florida also relied on media to share accurate and up-to-date information and to enlist the public’s help in fighting Zika transmission. At the time of writing, Florida Department of Health continues to publish daily Zika updates, as well as the department’s process for Zika testing and investigation. Educational campaigns such as “Be a Hero. Spill the Water!” use social media and advertising to enlist residents’ help in preventing the spread of Zika by reducing mosquito breeding areas.
The Pennsylvania Governor’s Office broadcast on Facebook a July 2016 Zika Town Hall meeting with the state’s departments of health and environmental protection. Pennsylvania also continues to update its Zika web page.
- Cultivate Collaboration and Partnerships.
One Texas official noted the importance of collaborating with federal, state, and local partners when planning for and responding to emergencies. For example, Texas Medicaid covers insect repellent and other Zika-related items for some populations, the federal CDC provided expertise and nationwide coordination, and local officials were instrumental to mounting an on-the-ground response.
A Florida official reported that robust partnerships are integral to the state’s Zika response. The Florida Department of Health refers pregnant women to the Healthy Start Coalition for care coordination and assistance applying for Medicaid if applicable. Infants born with Zika also receive support from the Department’s Early Steps program, which has local offices and partners statewide.
Pennsylvania engaged cross-sector partners such as the March of Dimes and blood banks, as well as targeting communications to healthcare providers. Because the state did not have an existing birth defects registry, the March of Dimes’s birth defect surveillance was a helpful complement to the state’s disease monitoring and reporting infrastructure.
All three states acknowledged the importance of engaging local officials in emergency planning and response. State leaders have worked with local health departments, local mosquito control and environmental protection entities, local elected officials, and other community leaders in responding to Zika. An effective local engagement infrastructure is especially important for states such as Texas with a system of local control that grants considerable autonomy to local public health entities.
- Develop and Maintain a Robust Public Health Infrastructure.
Robust public health data collection, monitoring, and laboratory testing capacity help states respond with agility to crises such as Zika. Florida’s birth defects registry, which has been operational since 1999, includes reportable conditions such as microcephaly that are potentially associated with Zika. The fact that this infrastructure was already in place permitted Florida to establish their baseline rate of microcephaly, which in turn helped the department monitor the possible impact of Zika on that rate.
States also identified the testing capacity and capabilities of their state laboratories as another key infrastructure element that supports emergency response. States that could test for Zika in-house—and had the capacity to meet the demand—were largely spared the delays and backlogs that could result when specimens have to be sent for out-of-state testing.
The Pennsylvania Department of Health built on the mosquito surveillance that the state’s department of environmental protection conducted for West Nile Virus. The existing cross-agency relationship between the two departments and the previous mosquito surveillance assisted the state with monitoring the potential for the disease to spread. The state law requiring infectious disease reporting was also broad enough to include Zika, which helped with surveillance efforts.
As these three tips show, state leaders can build upon existing communications, partnerships, and infrastructure capabilities to prepare for the challenges of the future, whatever form they take.