Significant state health policy changes are on the horizon as a result of Tuesday’s elections, which ushered in new governors and political changes in state legislatures across the country. Seven governorships (IL, ME, MI, NV, NM, KS, and WI) will switch parties and be steered by Democrats who all campaigned on health policy proposals. The election also resulted in political shifts in state legislatures, with Democrats now controlling both the executive and legislative branches in Colorado, Illinois, Maine, Nevada, New Mexico, and New York. Here is an overview of state health policy initiatives that could emerge in 2019.
Kansas and Wisconsin, which had rejected the Affordable Care Act’s (ACA) Medicaid expansion, will now have Democratic governors who strongly support expansion, but they could face legislative resistance. In 2017, the Republican-controlled House and Senate in Kansas passed a Medicaid expansion bill, but lacked the votes to override Republican Gov. Sam Brownback’s veto. While Wisconsin’s legislature already covers childless adults with incomes up to 100 percent of the federal poverty level in Medicaid, it is unclear if the legislature, still controlled by Republicans, will support expansion. In Georgia’s race, where final votes were still being counted, Democrat Stacey Abrams made Medicaid expansion a central campaign issue, but if elected she would need the support of a Republican-controlled legislature.
In Maine, where a 2017 referendum approved Medicaid expansion, but its implementation was blocked by Republican Gov. Paul LePage, newly-elected Democratic Janet Mills will assure that it is carried out with support from the state’s newly-elected Democratic House and Senate. In Idaho, Nebraska, and Utah, voters followed Maine’s lead and supported ballot measures to expand Medicaid, which will provide coverage to an estimated 300,000 individuals in these states. Unlike what occurred in Maine, Idaho’s newly-elected Republican Gov. Brad Little indicated before the election that he would not block implementation of expansion if voters passed the initiative.
In Nebraska, the re-elected Republican governor strongly opposes expansion, but during his campaign signaled the issue was up to the voters. Utah has submitted a waiver to federal officials to implement a partial Medicaid expansion that was approved by the state legislature, but with the passage of the ballot initiative full expansion will be implemented unless blocked by Gov. Gary Herbert, who has expressed opposition. Voters in Montana did not approve continuation of the state’s existing Medicaid expansion through a tobacco tax, and so the state legislature will need to decide before July 2019 whether to provide funding to continue the expansion.
Ohio’s new Republican Gov. Mike DeWine pledges to continue the Medicaid expansion there, but indicated he will impose “reasonable work requirements” on newly-eligible adults. Recently, under Gov. Rick Snyder, Michigan submitted a waiver request to implement work requirements for the expansion population, but Governor-elect Gretchen Whitmer has expressed opposition to Medicaid work requirements. Wisconsin also recently received federal approval to impose Medicaid work requirements on the childless adult population the state currently covers, and it is unclear if Governor-elect Tony Evers would seek to reverse these requirements.
Potential Comprehensive Health Coverage Reforms
Beyond Medicaid expansion, a number of newly-elected governors proposed comprehensive health coverage reforms. In New Mexico, Governor–elect Michelle Lujan Grisham, a former secretary of the state’s Department of Health, supports a Medicaid buy-in option. She also supports the New Mexico Health Security Act, a proposal to provide universal, publicly-supported health care based on a Medicare model through which commercial insurers provides supplemental coverage. In Illinois, Governor-elect J.B. Pritzker has called for implementing a Medicaid buy-in plan called “Illinois Cares” following an actuarial analysis to determine premium costs and cost sharing. Minnesota Governor-elect Tim Walz supports a public option modeled on MinnesotaCare, the state’s Basic Health Program. In Connecticut, Governor-elect Ned Lamont has proposed offering a Medicaid buy-in plan on the state’s exchange.
Maine’s Janet Mills calls for a public option – a Small Business Access Plan that includes self-employed individuals – that aggregates publicly-funded health plans and maximizes their buying power. In Colorado, Governor-elect Jared Polis wants to partner with other states to create a regional consortium with a common payer system to reduce costs, enhance coverage, and improve care quality.
Plans to Address Health System Costs
Polis in Colorado also proposed one of the most comprehensive state plans of the election season to address health care costs. He plans to target health care prices, noting that hospital consolidation or regions with only one hospital result in what he calls abuses of power in insurer–provider negotiations. He seeks more transparency in hospital pricing and stronger insurance rate review. His proposal could include creating a single geographic rating rule that would limit pricing differentials across the state, as well as examining the potential for global budgets to incentivize innovation, efficiency, and a focus on the social determinants of health. He also supports alternative payment approaches, including bundled payments and local models like community purchasing groups to level the playing field and ensure patients’ interests come before a hospital’s profit margin. Polis also wants to increase support for the state’s all-payer claims database (APCD) and use data to identify areas for cost savings.
Minnesota Governor-elect Tim Walz pledges to establish the One Minnesota Coalition to reduce health care costs and increase access. He also highlights the state’s medical research community and identifies opportunities to improve prevention strategies to reduce costs. In Connecticut, Governor-elect Ned Lamont identifies hospital consolidation as a cost driver and will seek legislation to address the issue and increase competition. He seeks a reasonable cap on facility fees, an end to surprise billing by facilities, and would require providers to publish plain-language disclosures of unexpected costs. Lamont also wants to reorient the state employee health care system around value-based care, require greater transparency from the state’s health care vendors, and implement innovations in preventive and primary care, such as on-site clinics that can improve employee health and productivity. Nevada’s Governor-elect Steve Sisolak plans to create a Patient Protection Commission to address health care prices and report recommendations addressing cost and access within 100 days.
Reinsurance and Proposals to Related to Individual Market Coverage
Newly-elected governors Whitmer of Michigan, Polis of Colorado, and Lamont of Connecticut all support a reinsurance program to lower rates in the individual insurance market. To improve affordability and access to individual health insurance, Lamont supports an extended open enrollment period for the state’s health insurance exchange, Access HealthCT. He plans to seek legislation to limit short-term plans to six months and require them to cover pre-existing conditions. Lamont, like Mills in Maine, vows to continue consumer protections in the ACA in the face of any federal roll-backs. In Nevada, Sisolak seeks to expand insurance options for the middle class who are not eligible for subsidies, and may consider a reinsurance plan for insurance companies that participate in rural markets. Maine’s Mills also supports well-regulated association health plans.
Reducing Prescription Drug Costs
Rising pharmaceutical costs is another issue that may receive more attention from a new slate of governors. A number of governors-elect indicated support for Canadian importation programs, maximizing purchasing power, alternative payment models, increased transparency, and other innovative plans to better control drug costs.
- Importing drugs from Canada: Democratic governors-elect Polis and Evers have specific plans to end prescription drug price gouging, which both include importing drugs from Canada. Whitmer and Mills also highlighted Vermont’s recent drug importation legislation as a possible solution to curb rising drug prices in Michigan and Maine, respectively.
- Increasing purchasing power: Four Democratic governors-elect — Evers in Wisconsin, Sisolak in Nevada, Michelle Lujan-Grisham in New Mexico and Mills in Maine — have expressed interest in bolstering their states’ purchasing power. Evers plans to partner with other states and require state agencies to work together to maximize Wisconsin’s bargaining. Sisolak aims to create Silver State Scripts, a network of insurance purchasers that would leverage its collective purchasing power for cheaper drugs. In Maine, Mills plans to explore pooling the purchasing power of public health plans to negotiate better deals. Similarly, Lujan-Grisham wants to harness New Mexico’s combined purchasing power of Medicaid and public employee and retiree health plans to drive down costs.
- Holding pharmaceutical companies accountable: Many governors are eager to hold pharmaceutical companies accountable for the rising costs of prescription drugs. In Wisconsin, Evers’ pharmacy cost plan includes establishing a drug price review board and empowering a consumer watchdog to review pharmaceutical drug price increases. In Connecticut, Lamont wants manufacturers to report and justify price increases so the state can block unnecessary price hikes. Whitmer plans to implement transparency standards in Michigan modeled after existing laws in California, Nevada, Oregon and Vermont. Polis plans to improve support for Colorado’s APCD and require pharmaceutical companies to disclose pricing and justify any increases that outpace inflation. Ohio Republican Governor-elect DeWine also supports more transparency in drug pricing to address costs. Mills in Maine wants to hold pharmacy benefit managers to strict financial scrutiny.
- Payment reform: A handful of governors-elect expressed plans to implement new payment models for prescription drugs. Evers wants to explore pay-for-performance and incentive-based pharmacy models in Wisconsin, while Lamont has expressed interest in value-based pricing models and a subscription model for Connecticut, similar to a plan recently proposed in Louisiana, in which the state pays a flat fee for access to certain drugs.
- Other plans to tackle drug costs: Whitmer plans to repeal state Sen. Bill Schuette’s Drug Industry Immunity Law, which makes Michigan the only state in the country that gives pharmaceutical companies immunity from fraud charges. In Connecticut, Lamont is interested in implementing utilization management measures to better control drug spending. He wants to explore a model similar to New York’s Medicaid Drug Spending Cap, which allows the state to address excessive price increases and seek more reasonable rates.
Health Care Workforce
In New Mexico, Lujan Grisham supports new strategies to address health care workforce shortages. Polis is calling for more clinics and telehealth in rural Colorado, expanding providers’ scope of practice, licensing reciprocity to address workforce shortages, and possible expansion of the state’s health services corps. In Nevada, Sisolak has also vowed to address the severe shortage of medical professionals in the state by providing more vocational training and reforming Medicaid reimbursements to help retain primary care physicians. Whitmer has also taken on health care workforce issues, including addressing nursing shortages and expanding telemedicine. Other new governors from both parties have expressed support for increasing access to telemedicine to address provider shortages in rural areas, including those in Florida, Nevada, Oklahoma, and Tennessee.
Social Determinants of Health
Whitmer’s comprehensive proposals are framed as “Healthy Michigan, Healthy Economy” and address public health and the social determinants that drive costs, including proposals to address food insecurity, invest in outdoor recreation, raise the age to purchase tobacco to 21, and launch a “Get Fit Michigan” campaign. Lamont of Connecticut wants to invest in public health and the social determinants of health by incorporating interventions in housing, education, poverty, and the environment. In Ohio, DeWine calls for expanded wellness initiatives to improve health outcomes, including requiring Medicaid managed care plans to provide health education and promote prevention initiatives. Tennessee’s governor-elect plans to reduce preventable disease by providing patient education resources to encourage healthy lifestyles.
Addressing the Opioid Epidemic
Most candidates addressed the opioid crisis and highlighted initiatives to better address mental health issues. Among opioid proposals, Polis of Colorado supports more focus on the epidemic and better integration of physical and behavioral health care. Lamont of Connecticut plans to strengthen the state’s efforts to address the opioid crisis by appointing a cabinet-level position to coordinate a multi-agency response. In Ohio, DeWine proposes a 12-point comprehensive plan and advocates for a multi-faceted approach involving law enforcement, community outreach, and education. Michigan’s Whitmer seeks to expand treatment services, invest in treatment courts, and hold physicians and drug companies accountable.
Clearly, 2019 promises to be a year of lively state health policy debate and action across the nation. Along with the strategies outlined here, there will be new proposals from governors who may take a more market-driven approach to policy and who may seek to take advantage of new Trump Administration authorities to restructure health care and provide different options to consumers. The National Academy for State Health Policy will work with all states and continue to report on their progress in advancing health reform proposals.
Below is a full list of the Conference speaker presentations.
- Sandra Robinson
- Daniel Cohen
- Kevin Cranston
- Kristina Larson
- Jacqueline Clymore
- Heather Hauck
- Joseph Kerwin
- Pete Liggett
- David Neff
- Michael Wofford
- Karen Robinson
Thursday Morning Plenary: Understanding the Health Care Cost Conundrum
Session 3: May the (Work) Force Be with You
Session 4: Cha-Ching! Lowering Rx Costs
- Greg Poulsen
- David Seltz
- Erin Taylor
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.
Thursday, August 16th
10:00am – 11:30am
Transitioning from youth to adulthood requires increased responsibility for many areas of life, including managing one’s health. This can be particularly challenging for children with a range of social and health care needs, particularly children with special health care needs. Policymakers from several states, including Georgia and Wisconsin, discuss innovative approaches to support young adults’ transitions to adult health care services and programs through managed care, quality improvement, family engagement, care coordination, and interagency collaboration and cooperation.
This session is supported by the Lucile Packard Foundation for Children’s Health
ModeratorsLori Abramson, Director-Georgia Families 360, Georgia Department of Community Health
Lori Abramson, LCSW is Director of the Georgia Families 360° program at the Georgia Department of Community Health. She ensures that children in foster care, adoption assistance, and youth in the juvenile justice system receive medical, dental, and behadvioral health care without barriers. Lori has 38 years’ experience in clinical practice, advocacy, collaboration building, and the managed care environment. Lori’s professional focus is about leveraging that experience on behalf of Georgia’s children and families.
Donna Bradbury, Associate Commissioner, NYS Office of Mental Health
Donna Bradbury directs the Division of Integrated Community Services for Children and Families at the Office of Mental Health. She oversees all community-based children’s mental health programs in New York State. She is currently leading the effort to transition children’s behavioral health services into Medicaid managed care as part of the larger Medicaid Redesign project.
Prior to state service, Donna worked for twelve years for the Rensselaer County Department of Mental Health. She delivered clinical services to children and their families, served as a consultant to Family Court as well as county-operated human service departments and schools, ran a specialized treatment program which successfully prevented institutional placement for many youth, and assisted in the creation and implementation of several interagency initiatives that resulted in children and their families having easier access to better quality services.
SpeakersBecky Burns, Statewide Coordinator, Wisconsin Children and Youth with Special Health Care Needs Program
Becky’s career centers on supporting children and families whose lives have been affected by unanticipated journeys through the world of disability services. She treasures the opportunities to work with these families whose resilience and growth continues to astound her. With a Master’s of Science in Social Work, she has used her education along with her personal experience of being raised in a family with a child who has a disability to influence her work with families. She has worked in one capacity or another for the state of WI for over 18 years.
Gordon Lee, Health Program Administrator, KY Office for Children with Special Health Care Needs
Peggy McManus, President, The National Alliance to Advance Adolescent Health
Peggy McManus is President of The National Alliance to Advance Adolescent Health and Co-Director of Got Transition. With Dr. White, she led the revision of the Six Core Elements of Health Care Transition, developed new transition quality improvement and consumer feedback measurement tools, published systematic reviews on transition outcomes and measures, and published extensively on transition quality improvement, payment options, state Title V transition efforts, and the status of transition preparation in the US.
Do you really know what’s driving up health care costs in the United States? Take this true or false quiz to separate fact from fiction.
It’s common knowledge that health care spending in the United States is much higher than in other developed countries, and our out-sized spending doesn’t even help us live longer. A new Journal of the American Medical Association article, which compares health care costs in America with 10 other countries, is required reading for state policy leaders who are looking for levers to reduce health care spending. Take this quiz for a reminder about what’s really behind spiraling health care spending.
The United States spends nearly twice more of its GDP on health care than does Australia, Canada, Denmark, and Japan. True or false?
True. America spends 17.8 percent of its GDP on health care services, compared to the four countries that spend between 9.6 to 10.5 percent of their GDP on health care.
America’s costs are higher because we go to the doctor more often. True or false?
False. Americans see doctors at about the same rate as in other countries.
America’s costs are higher because we have more specialists. True or false?
False. We have about the same number of specialists, per population, as other countries.
Health care in America costs more because our doctors order more tests. True or false?
True. American doctors order more tests and procedures than other countries. America ordered the highest number of CT scans and the second-highest number of MRIs per 1,000 population among the countries surveyed.
These medical tests and procedures cost more in America than in other countries. True or false?
True. An MRI costs $1,150 on average in the United States, compared to about $140 in Switzerland, and a CT scan costs $896 in the United States, compared to $97 in Canada.
These additional medical tests result in better health outcomes. True or false?
False. Despite all that spending, our life expectancy is the lowest and infant mortality is the highest among the countries surveyed, especially among poor and non-white populations.
In the United States, high-cost procedures, such as knee replacements, cataract surgeries, angioplasty, and coronary-bypass grafts, are performed more often than in developed countries. True or false?
True. Not only were these procedures performed more frequently in America, their price tag was much higher. And, some of these procedures inevitably led to costly complications that health plans, Medicaid, and Medicare had to pay for. These extra tests and procedures did not improve life expectancy or reduce infant mortality.
In the United States, people are hospitalized more frequently, which drives up costs. True or false?
False. America has about the same number of hospital beds, discharge rates, and hospitalizations per population as the other countries. It spent 19 percent of its total health care expenditures on inpatient care, which was the second-lowest among the 11 countries in the study.
America spends much more on outpatient care than do other countries. True or false?
True. Most of these high-cost tests and procedures are performed on an outpatient basis. As a result, America spent 42 percent of its health care expenditures on outpatient care, compared to France, Germany, and The Netherlands, which spent less than 23 percent.
Americans spend about the same on prescription drugs as those in other developed countries. True or false?
False. Americans spend about $1,443 annually per person because medication costs more here than abroad. Need some examples? One Lyrica pill costs $6.04 in the United States and 63 cents in Canada. One capsule of the hepatitis C drug Harvoni, invented in the United States, costs $1,090 here and $798 in Canada.
Administrative and provider costs are higher in the United States, which contributes to soaring health care costs. True or false?
True. Administrative costs of managing health systems and services, which include handling insurance billing, accounted for 8 percent of US health care costs, compared to 1 to 3 percent in the other countries. US salaries for physicians and nurses were higher, averaging about $218,173 annually for a US generalist physician, compared to a doctor’s average salary of $86,607 in Sweden and $154,126 in Germany.
Bottom line, researchers found that high provider, administrative, pharmaceutical, and medical device prices drove up health care costs in the United States. “As patients, physicians, policy makers, and legislators actively debate the future of the US health system, data such as these are needed to inform policy decisions,” they concluded.
Last week, 24 National Academy for State Health Policy (NASHP) leaders, including state lawmakers and representatives from governors’, budget, and insurance offices, Medicaid and public health agencies, and insurance exchanges, CHIP and health policy commissions met in Washington, DC, to assess the issues and opportunities confronting state health policymakers. The robust discussion helps NASHP set its priorities for action and informs the annual NASHP conference agenda.
While NASHP members approached the discussion from markedly different states and perspectives, several clear themes emerged.
Costs, costs, costs: A recent Journal of the American Medical Association article that highlighted the high price of health care in the United States – double what is spent in other, developed countries due to high-priced services, drugs, devices, and administrative costs – helped frame the critical issue of cost and affordability. Members were eager to talk in-depth about:
- The role of value-based purchasing, and how policymakers can measure value and at what price.
- How investments in the social determinants of health (e.g., housing, nutrition, and education) can truly bend the health care cost trajectory.
- Is there more do to with reference pricing and giving consumers more power to shop?
- Are there better ways to manage long-term services and supports and provide effective chronic care and end-of-life support?
Members encouraged NASHP to continue its work to address rapidly-rising pharmaceutical costs and to expand that effort to address other drivers of escalating health care costs.
The changing health care marketplace: Consolidation of health providers, emergence of new players in the field such as the Berkshire-Hathaway proposal, and new mergers and acquisitions throughout health care raised questions about whether states’ current regulatory structures are keeping pace with these changes.
- What is the role of state insurance regulators as providers develop new models of care and take on financial risk, a role that has historically been the purview of insurance companies?
- Does the certificate of need program need to be re-examined and reformed to adapt to the changing market?
- Do states have adequate data infrastructure to track and predict these changes?
Coverage and federal uncertainty: Officials reflected on a year of uncertainty and recounted their efforts to sustain programs while awaiting federal action or responding to federal changes. Children’s Health Insurance Programs (CHIP) were in limbo, but states managed to maintain coverage until Congress made a much-delayed decision to continue federal financing for 10 years.
Insurance regulators and state insurance exchanges reacted quickly to keep coverage in the individual market affordable when the Administration stopped funding cost-sharing reductions in the eleventh hour last fall. Now, they must contemplate how to sustain markets in light of proposed federal plans to extend short-term duration plans and launch association health plans that are exempt from Affordable Care Act rules. which could pull enrollees out of state marketplaces with their low-cost, low-benefit plans.
As the Centers for Medicare & Medicaid Services allows more flexibility in Medicaid programs, what does that mean in practice? How will work requirements play out? What other approaches might states take?
Health care workforce: A changing health care environment creates the need for new approaches to deliver care, such as telehealth, but NASHP members shared an overriding sense of urgency to address the growing demand for a health care workforce in both rural and urban areas. They reported challenges in their home states in every area of health care, including physicians, nursing, therapists, community health workers, dental providers, behavioral health practitioners, and long-term services and supports staff. Without an appropriate workforce, state efforts to improve care integration and delivery and payment reforms will be hindered. What can states do through licensure, education, salary, and benefits to expand this vital workforce? And, how does federal immigration policy affect the availability of these critical workers?
Improving health: As state leaders face day-to-day challenges, the over-arching focus of their work is to improve population health and directly address the social determinants that impact health so profoundly. The opioid crisis continues to demand leaders’ time and action, but comprehensive work is also underway to build sustainable systems to improve health. Leaders discussed new ideas to:
- Create or strengthen linkages with school health programs;
- Improve transitions for youth with disabilities who age out of supportive services;
- Assist those leaving corrections systems;
- Help children and youth with special health care needs; and
- Employ new, evidence-based approaches that strengthen early child development.
Throughout the conversation, leaders stressed the need for state officials to break out of funding and administrative silos so they can work collaboratively and creatively to develop and implement efficient and effective policies during this period of uncertain federal priorities and funding.
Armed with these insights and concerns, NASHP will continue to work in these key areas and address them at its annual health care policy conference from Aug. 15 to 17, 2018, in Jacksonville, FL.
One out of twelve Americans and one out of six adults and children covered by Medicaid and the Children’s Health Insurance Program (CHIP) receive their care at health centers funded in part by the federal Health Center Program. Funding uncertainty for this program and two other federal safety net programs — the National Health Service Corps (NHSC) and Teaching Health Center Graduate Medical Education Program (THCGME) – could have long-term consequences for states and their Medicaid and uninsured populations’ access to critical health care.
Collectively, these programs support health centers and other safety net organizations that provide access to physical, behavioral, and oral health care to millions of low-income and underserved people.
Mandatory federal funding for these programs expired in 2017. Congress voted to reauthorize short-term support for these programs at reduced funding levels through March 31, 2018, as part of the Continuing Resolution passed on Dec. 21, 2017. Table 1 shows a comparison between spending in fiscal year (FY) 2017 and the current, temporary funding authorized in FY 2018 for these three federal programs.
Table 1: Comparison of FY 2017 Safety Net Program Funding and FY 2018 Temporary Funding
|Program||Scope||FY 2017 budget||FY 2018 funding authorized by the Continuing Resolution|
|Health Center Program: Health centers offer a wide array of services, including physical, behavioral, and oral health services, as well as substance use disorder treatment and recovery services. Health centers also frequently partner with social service organizations to connect patients to legal aid, food/nutrition support, patient education, and housing.||Health centers served about 26 million patients in 2016.
Health centers employ over 200,000 clinical professionals and staff.
|About $5 billion
($3.6 billion was mandatory funding from the Community Health Center Fund; $1.2 billion was discretionary funding)
|$550 million for first two quarters of FY 2018|
|National Health Service Corps: NHSC supports medical, behavioral health, and dental professionals with loan repayment, and provides scholarships to health professions students who commit to provide primary care in low-income and medically-underserved areas across the country.||10,000 health professionals receive loan repayment support.
1,400 health professions students receive scholarships.
($360 million in mandatory funding; $20 million in discretionary funding)
|$65 million for first two quarters of FY 2018|
|Teaching Health Center Graduate Medical Education Program: THCGME supports primary care residency positions in low-income and medically underserved areas in 24 states. Residents are primarily placed in health centers.||More than 700 primary care residency positions.||$60 million in mandatory funding||$30 million for first two quarters of FY 2018|
What Can States Expect?
Funding uncertainties are already impacting these health centers. Current, short-term funding for the Health Center Program and NHSC is significantly less than what these programs received for the first two quarters of FY 2017. Continued disruptions resulting from reduced or eliminated funding could exacerbate existing state safety net challenges.
- Access: Health centers that receive Health Center Program funding have an open door policy, providing services regardless of insurance status or ability to pay. States that have not expanded Medicaid may be particularly hard-hit by continued instability at health centers, some of which have already started to close clinic sites, reduce available services, limit hours, and impose hiring freezes or wage reductions. Additionally, clinical professionals may seek more financially secure positions in other settings, exacerbating health centers’ ability to recruit and retain providers.
- Opioid treatment and mental health: Health centers are an important providers working in states to tackle the opioid crisis and provide access to integrated behavioral health services. More than 6 million patients served in health centers in 2016 had a primary diagnosis of a mental health or substance use condition. Reduced capacity for these services, particularly in underserved rural areas, could undermine ongoing state efforts to expand and improve substance use and mental health treatment and recovery.
- Emergency department utilization: Reduced access to primary care and behavioral health services could drive more Medicaid and uninsured patients to seek regular care in hospital emergency departments, particularly in rural and underserved areas, increasing state Medicaid costs and hospital uncompensated care.
- Delivery system initiatives: States that have incorporated safety net providers into delivery system reform efforts (such as Section 1115 waiver’s Delivery System Reform Incentive Payment program) may find these providers have less capacity to participate in quality improvement, care coordination, and other key initiatives that can improve care and reduce costs.
- Clinical workforce: Reductions in NHSC or THCGME means health centers and other safety net providers will have fewer incentives to recruit and retain clinical professionals to work in medically underserved areas. Moreover, states that receive NHSC State Loan Repayment Grants to help support state-based incentive programs may need to shoulder more of these costs in the future.
States’ ability to provide access to care for vulnerable, low income populations depends on these safety net programs. Without Congressional action before the end of March, when the short-term funding runs out, funding for these programs will remain in jeopardy.
National reports show it takes 17 years before medical research is put into practice by health care providers. Why does it take so long? Are there levers or tools, such as payment incentives or provider education, that state health policymakers can use to bridge that gap?
The National Academy for State Health Policy (NASHP) recently convened a workgroup of state policymakers to monitor emerging patient-centered outcomes research and explore potential policy implications. The group will also provide guidance on effective dissemination and implementation strategies that could lead to putting research into practice sooner. The workgroup includes officials from 10 states, including Medicaid, insurance, patient, mental health, labor, and public health representatives and state legislators.
NASHP, in partnership with the Center for Evidence-based Policy and with support from the Patient-Centered Outcomes Research Institute (PCORI), kicked off the workgroup in January 2018 by exploring two recently-published studies. The first examined interventions to address childhood obesity and the second assessed the impact of a shared decision-making tool for patients presenting in the emergency room (ER) with chest pain — the second most common reason for ER visits in the United States, which represents 8 million annual visits. Both studies were funded by PCORI, which supports comparative effectiveness research and engages patients at every step of the research process so their perspectives inform research topics, design, and outcomes, which benefit them as the ultimate health care user.
The workgroup considered the research and raised two key questions about when and how they should engage with research to improve health care in their states:
- Does this evidence merit action?
- If yes, how is this evidence actionable? What policy levers, strategies, or tools can state health policymakers use to put this evidence into practice?
When Does Evidence Merit Action?
Policymakers are generally hesitant to make decisions based on a single study, and instead seek to understand evidence based on a wider body of literature. To help with that process, the Center for Evidence-based Policy presented relevant systematic reviews to the workgroup on childhood obesity interventions and shared decision making. These reviews helped the workgroup members establish that the studies and their findings were consistent with the published literature.
PCORI is also helping to put research into context for policymakers by piloting economic impact models for a number of PCORI-supported studies. For example, one study examined self-monitoring of blood sugar levels among patients with type 2 diabetes who are not using insulin. At the end of the one-year study, there were no differences in blood sugar levels and quality of life between patients who checked their blood sugar levels with finger pricks daily and those who did not. These findings illustrate the potential for cost savings on unnecessary testing supplies, savings that would be magnified if the research is adopted more widely into practice.
How Is Evidence Actionable?
When research merits action because of its health and/or economic impact, what policy levers do state health policymakers have? The answer to this question is not always obvious, especially when the research focuses more on a clinical level rather than at a health program administrative or delivery systems level. State officials, however, are eager to consider what actions they may be able to take when the evidence supports a change or new direction.
- Could a state Medicaid agency seek to use payment as a lever to encourage providers or consumers to utilize certain services?
- For example, the US Centers for Disease Control and Prevention’s 6/18 Initiative is working with Medicaid programs to use payments as a lever to advance evidence-based prevention, such as eliminating copays for smoking cessation programs in South Carolina.
- Are there opportunities for states to use their managed care health plans to put evidence into practice? When appropriate, could a managed care organization implement a change through quality improvement efforts?
- For example, Tennessee, as part of its Medicaid quality improvement efforts, is increasing the use of pediatric preventive services by creating incentives for managed care organizations through a pay-for-performance program.
- Are there educational outreach strategies such as practice facilitation or academic detailing that a state could use to implement evidence in practice?
Looking forward, the workgroup expressed interest in exploring emerging evidence related to improving health care systems such as care coordination efforts through behavioral health homes or emerging workforce roles such as peer health navigators. They also expressed interest in studies related to reducing disparities through tele-health. Future blogs will explore discussions of policy implications of new research on these topics and others.
 Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
 Emma Mead, et al. “Diet, physical activity and behavioral interventions for the treatment of overweight or obese children from the age of 6 to 11 years,” Cochrane Database of Systematic Reviews 2017. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012651/abstract
 Dawn Stacey, et al. “Decision aids for people facing health treatment or screening decisions,” Cochrane Database of Systematic Reviews 2017. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001431.pub5/abstract
 For more information, see NASHP’s recent brief: Lessons in Advancing Evidence-Based Primary Care from the Heart of Virginia Healthcare EvidenceNOW Cooperative