Governors’ state of the state and inaugural addresses provide critical insights into their policy proposals that impact the health of their residents. Last week, the National Academy for State Health Policy (NASHP) highlighted the health care issues governors raised in their 2019 addresses. This week, NASHP examines the social and economic issues raised – such as poverty, violence, housing, education, and addiction — that heavily impact the health and well-being of Americans.
By early February, 2019, 48 governors, including 20 newly elected, had outlined policy priorities in their speeches.* Of the health-related social and economic factors identified in their speeches, governors most commonly mentioned plans to address education, jobs, and infrastructure, followed by opioids and the environment. Other topics included violence prevention, child welfare, justice, equity, and cannabis. Ten governors discussed plans to develop new government structures to coordinate services efficiently.
Given that health is shaped by myriad conditions in which people live, work, and age, it is not surprising that many topics interrelate and cross sectors. For example, governors who mentioned plans to address workforce training and job readiness touched on both education and employment as key issues.
Of the 40 governors who addressed education, many highlighted early education, student health and mental health, student debt relief, and increased resources for schools:
- New Mexico Gov. Michelle Lujan Grisham: “I reject the false choice of today’s children or tomorrow’s budget. We must dramatically increase our Pre-K and educational investments today and provide sustainable revenue for the long term. I have also proposed an expansion of the Working Families Tax Credit, which we know creates a ladder out of poverty, providing child care programs so parents can continue to get meaningful support even as they do the hard work to transform themselves and their family’s fortunes for the better.”
- Ohio Gov. Mike Dewine: “Our plans to intervene early in the lives of at-risk kids, to address their physical and emotional needs, and to give them better, higher-quality educational opportunities — all will be undertaken in the faith and hope and confidence that these children will flourish and grow and that their lives will be forever changed by the things that we do. Education is the key to equality and to opportunity.”
Of the 37 governors who addressed jobs, many focused on workforce readiness, public employee and teacher wages, and minimum wage:
- Nebraska Gov. Pete Ricketts: “The first pillar is making sure we’re connecting Nebraskans to great paying jobs and that they’ve got the skills to be able to take those jobs. … As previously announced, I am recommending the creation of the Nebraska Talent Scholarships program to help our community colleges, state colleges, and the university system attract even more students in targeted programs from engineering to health care with over 2,100 new scholarships. Additionally, I am recommending the expansion of the Developing Youth Talent Initiative to connect more middle school students to opportunities in manufacturing and IT with an additional $1.25 million annually. This program has already impacted 7,000 students, and this expansion will help reach even more.”
- New Hampshire Gov. Chris Sununu: “I will be proposing the state’s single largest ever investment into workforce training — a $24 million one-time investment — to grow our state’s nursing and health care workforce and double the number of those graduates in New Hampshire schools.”
Twenty-two governors mentioned plans to address the opioid epidemic. This analysis specifically focuses on the preventive aspects of their plans, including efforts to address mental health:
- Vermont Gov. Phil Scott: “In my first budget address, I talked about the most undeserving victims of our opioid crisis: the children born to addiction. That day — two years ago — I vowed we would not fail them. This budget continues to support our investments in prevention, treatment, recovery, and enforcement. And with an increased investment of $2 million to the Family Services Division, we can give these children more of the support, hope and opportunity they deserve.”
- South Carolina Gov. Henry McMaster: “Last year, I declared a statewide public health emergency, mobilizing the full power of the state’s emergency infrastructure in response to the growth of opioid addiction and abuse. And I signed what must be the most comprehensive set of laws in the country addressing this crisis across the spectrum of law enforcement, education, and health care…. For instance, our doctors are now required to educate minors and their families on the dangers of opioids before prescribing them; the Department of Health and Environmental Control is issuing tamper-proof prescription pads; the anti-overdose drug Narcan is more readily available; and initial prescriptions are now limited to seven days. I also established the Opioid Emergency Response Team, which in June released a plan consisting of recommendations on physical and public education, prevention and response, treatment and recovery, and law enforcement approaches.
Twenty-eight governors mentioned infrastructure issues, from high-speed internet to active transportation, to bridge and road repairs. Georgia Gov. Brian Kemp promised to bring high-speed internet to rural areas and Kansas Gov. Laura Kelly promised, “In the coming days, we will build an interconnected, strategic plan for rural economic development that leverages our communities’ unique assets. That means developing infrastructure.”
Twenty-five governors mentioned environment goals, including clean water, clean and renewable energy, climate change, and environmental protection:
- Maine Gov. Janet Mills: “The Gulf of Maine is warming faster than almost any other saltwater body in the world, driving our lobsters up the coast. Our coastal waters are growing acidic, temperatures are fluctuating, and sea levels are rising, endangering our shellfish industry. Our forests are less suitable for spruce and fir and more suitable for ticks. Climate change is threatening our jobs, damaging our health and attacking our historic relationship to the land and sea.”
- Florida Gov. Ron DeSantis: “Our economic potential will be jeopardized if we do not solve the problems afflicting our environment and water resources. …We will fight toxic blue-green algae, we will fight discharges from Lake Okeechobee, we will fight red tide, we will fight for our fishermen, we will fight for our beaches, we will fight to restore our Everglades and we will never ever quit, we won’t be cowed and we won’t let the foot draggers stand in our way.”
Sixteen governors called for increased access to affordable housing and/or reductions in homelessness:
- Nevada Gov. Steve Sisolak: “I will be supporting the recommendation to create a new program which will offer $10 million of state tax credits per year for the creation and preservation of affordable housing.”
- Oregon Gov. Kate Brown: “[W]e can speed up construction of 200 units of permanent housing for the chronically homeless. We also need to help Oregonians who have homes but are struggling with the high cost of rent. When problems arise, they need technical assistance to stay in their homes and not end up on the streets. We can help landlords and tenants navigate this tight housing market.”
Eighteen governors identified a need to prevent gun violence and improve school safety:
- Delaware Gov. John Carney: “[W]e provided schools with new resources to make them safer, and passed responsible gun safety legislation. This included the Beau Biden Gun Violence Prevention Act.”
- Mississippi Gov. Phil Bryant: “A problem exists in our schools today that threatens children of all ages. It has become commonly known as the active shooter… I will ask you to pass a comprehensive plan to keep our school children safe. …If you will pass and fund the Mississippi Safe School Act, our parents, teachers and administrators will be allowed to care for our children in a safe and protected environment.”
Thirteen governors mentioned the need for equity in educational, employment, and other opportunities:
- Texas Gov. Greg Abbott: “We must ensure destiny is not determined by zip code. Students from the most challenging circumstances can perform at the highest levels. But we have to give them the opportunity to succeed.”
- Washington Gov. Jay Inslee: “We’re the state that’s going to tear down the systemic barriers to work and education faced by people of color, people with disabilities, veterans and women. …We’re the state that embraces our differences and diversity… We’re the state making sure our government looks like the people it serves.”
Other topics that impact health include efforts to improve the justice system, enhance child welfare, and structure state government more efficiently:
- Indiana Gov. Eric Holcomb: “We’ll continue to be transparent and accountable on pressing issues like child welfare…. A year ago we had just started a top-to-bottom review of the Department of Child Services (DCS). Now, we are moving full speed ahead on addressing all those 20 recommendations that not only protect children but recognize the difficult work of those who protect them. It’s still early, but the investments we’ve made to increase caseworker salaries and improve the workforce culture are making a difference. The ratio of supervisors to case managers has improved, so there is more time for supportive supervision and coaching. Turnover among frontline staff is down and retention is up, which means more stability between caseworkers and the families they work with. And, fewer children are reentering the DCS system after their cases close.”
- North Dakota Gov. Doug Burgum: “We’re creating a unified IT Shared Service organization. Already, we have aligned the backend systems of 31 state agencies, saving more than half a million dollars… We created the Office of Recovery Reinvented to promote these [behavioral health] efforts with help from behavioral health professionals and community and tribal leaders.”
- Pennsylvania Gov. Tom Wolf: “Our differences haven’t stopped us from putting a down payment on criminal justice reform with the Clean Slate bill… I want us to be ambitious in imagining the Pennsylvania we can build together… Where we reform a criminal justice system that treats African Americans and the poor unjustly.”
Governors’ plans to address these social and economic issues have clear implications for their residents’ health. NASHP will continue to track these proposals and other, related state initiatives in the coming year.
* For some states, information from both a governor’s inaugural address and a state of the state address was included in this review. For others, information from only one speech is incorporated due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred, the inaugural address served as the governor’s primary policy speech and no state of the state address is planned, or the governor did not have an inauguration and delivered only a state of the state address. As of Feb. 5, 2019, Louisiana and North Carolina governors had not made speeches.
Produced in partnership with the de Beaumont Foundation and the Robert Wood Johnson Foundation.
State of the state and inaugural speeches give governors the opportunity to highlight their recent policy successes and outline key plans and priorities for the coming year. These speeches are strong indicators of governors’ policy goals and often include proposals and funding recommendations for their legislatures.
As a result of 2018 gubernatorial races in 36 states, there are 20 new governors and seven governorships (IL, KS, ME, MI, NV, NM, and WI) shifted from Republican to Democratic control. There are currently 27 Republican and 23 Democratic governors. As of mid-February, 48 governors had outlined policy priorities through their inaugural and/or state of the state speeches or budget addresses.*
Key Health Themes
Forty-five governors addressed health care in their speeches this year, and while many themes were similar to years past, a notable exception was the issue of health care costs and affordability, which emerged as a much more significant concern for governors this year. Twenty-four governors spoke of the need for affordable health coverage and others also addressed Medicaid costs and pharmaceutical pricing.
Behavioral Health Issues
Health issues related to mental health and substance use disorders (SUD) were the most commonly cited by governors. Thirty-seven mentioned these issues — the same number of governors who commented on behavioral health in 2018. Governors frequently highlighted strategies they had implemented or that they planned to implement to increase access to behavioral health services or restructure care systems. For example, New Hampshire’s governor commented on recent initiatives to establish mobile crisis teams and community wrap-around services and plans to continue to improve the quality of the state’s mental health system with an upcoming 10-year mental health plan.
Gov. Michelle Lujan Grisham plans to rebuild New Mexico’s behavioral health system and develop strategies to reduce cost, increase patient access, and focus on improved patient care, better health outcomes, and stronger relationships between patients and providers. In North Dakota, the governor is proposing to invest more than $19 million across a continuum of care services to address the state’s behavioral health issues. In Texas, the governor declared that mental health reform would be an emergency item for the 2019 legislative session.
Fourteen governors (AZ, CO, GA, IN, IA, KY, NH, RI, SC, TX, UT, WA, WI, and WY) referenced plans to increase access to mental health services in schools, with some citing the need to provide these additional services to help prevent school shootings. Iowa’s governor also emphasized behavioral health services for children, citing the recent creation of a children’s mental health board that focused on developing a cohesive children’s mental health system. She noted plans to build on the board’s recommendations, and requested that legislators provide additional funding for home- and community-based mental health services for children.
Twenty-six governors specifically mentioned current and future strategies to address the opioid epidemic — a slight decrease from 30 mentions in 2018 — but this demonstrates that the issue remains a top priority for many states. Ten governors also spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals as they transition back into communities and/or providing mental health and SUD treatment services rather than incarceration when appropriate.
Medicaid Program Reforms and Costs and Medicaid Expansion
In total, 23 governors mentioned Medicaid and/or Medicaid expansion in their speeches, which is similar to last year when 19 governors addressed these topics. Ten governors provided general remarks about their states’ Medicaid programs, highlighting recent program improvements, the growth of overall program costs, or plans to implement reforms to ensure the program’s sustainability. New York’s governor expressed concerns about upcoming Medicaid Disproportionate Share Hospital (DSH) cuts, and that previous proposals by federal policymakers to cut Medicaid funding have created uncertainty.
Fourteen governors specifically mentioned Medicaid expansion in their speeches. Some governors commented positively on expansion or the potential for it, with Maine’s newly-elected governor announcing plans to begin implementing the 2017 voter-approved expansion measure, which had been stalled by the former governor. Nebraska’s governor announced he would move forward with filing a state plan in accordance with the expansion ballot measure that state voters approved in 2018. Utah’s governor noted that while Medicaid expansion is needed, the 2018 voter-approved expansion should be implemented in a fiscally sustainable way, with “common sense adjustments.” Montana’s governor outlined in detail the positive economic effects and increased coverage rates that have resulted from implementing expansion and its importance in helping to sustain small businesses and rural hospitals. He indicated that he would not support adding measures to the state’s expansion model that could potentially reduce enrollment and be costly to administer, and recommended that legislators make expansion permanent. In contrast, New Hampshire’s governor urged the legislature to support the upcoming implementation of federally-approved work requirements for the expansion population, responding to some calls to repeal them.
Addressing Increasing Health Care Costs
In addition to mentioning Medicaid-related health care costs, 24 governors also addressed increasing health care costs more broadly, often mentioning that health care coverage needs to be more affordable for individuals and families. This is a notable increase from 2018, when only 11 governors mentioned the impact of rising health care costs. Colorado’s new governor is taking the bold approach of establishing a specific office to focus on reducing patient costs, improving price transparency, lowering prescription drug costs, and improving the affordability of health insurance. Montana’s governor highlighted the state’s reference-based pricing model for state employee health plans, which has made medical costs more consistent and comparable across facilities and in just two years has resulted in a $13 million reduction in state health plan costs. He also encouraged passage of legislation designed to address surprise medical bills.
Governors in Colorado, Montana, and Rhode Island have signaled plans to establish reinsurance programs in their states to address rising premium costs. Gov. Mark Gordon commented that there is an opportunity to “craft a Wyoming solution for health care” and develop state-led solutions to reduce costs.
Prescription Drug Costs
The rising costs of prescription drugs emerged as a new theme in this year’s speeches, earning mentions from seven governors. This is notable, given last year the issue was not addressed by any governor. Colorado’s governor advocated having residents pay a “fair price” for prescription drugs, and promised to work with the legislature to develop a wholesale importation program. Nevada’s governor plans to create the Patient Protection Commission that will identify options for protecting state residents from exorbitant prescription drug prices. The most comprehensive proposal was came from California’s governor who signed an executive order to establish the nation’s largest single-purchaser system for prescription drugs to leverage the state’s purchasing power as a way to lower drug costs.
Health Care Coverage
Eleven governors commented on potential changes that may occur to the Affordable Care Act (ACA) and health coverage in general. Many indicated they would take action to safeguard ACA coverage gains and insurance protection provisions. Nevada’s governor expressed support for defending the ACA and blocking any efforts to scale back protections for preexisting conditions, and Gov. Andrew Cuomo said New York should codify the ACA and incorporate preexisting condition protections into state law. Governors in Oregon and Rhode Island similarly pledged to protect coverage of preexisting conditions, and Wisconsin’s governor issued an executive order creating a Healthy Communities Initiative to promote affordable and accessible health care and another to ensure preexisting conditions were covered.
In his speech, Washington Gov. Jay Inslee promised to “fight for a public health option to ensure health care for all,” in reference to his recent proposal to offer a public plan through the state’s marketplace to make an affordable coverage option available across all regions of the state.
In California, Gov. Gavin Newsom proposes to provide Medi-Cal coverage to undocumented young adults up to age 26, and also seeks federal changes to allow states to implement even more comprehensive coverage reforms and move toward a single-payer model. He is also planning to increase the amount of subsidies available for marketplace coverage and would allow higher-income families to access ACA subsidies. To help cover the costs of this expanded financial assistance, Newsom’s budget proposes to implement a state-level individual mandate. Other states are also considering individual mandates — although not mentioned in recent state of the state speeches, the governor of Rhode Island’s budget proposal recommends implementing such a measure, and Nevada’s governor has indicated earlier that his proposed Patient Protection Commission would examine the issue.
Health Care Workforce
Fourteen governors addressed health care workforce issues, primarily identifying strategies to address provider shortages. This is similar to 2018, when twelve governors mentioned health care workforce issues. This year, governors in Missouri and South Carolina commented about current and planned investments in telehealth to increase access to providers in rural areas. Governors in Mississippi, Nebraska and Oklahoma expressed plans to either create or expand existing scholarship programs to help increase the number of physicians in rural areas. New Hampshire’s governor proposed a $24 million investment to increase the state’s nursing and health care workforce. Other governors in Iowa and Washington highlighted strategies to enhance the capacity of the behavioral health workforce.
Miscellaneous Health Issues
Most governors mentioned other health-related topics in their speeches, either as recent accomplishments or as future plans. These included support for seniors, disabled individuals, and/or children in foster care; women’s health issues; and efforts to address broader social and/or environmental issues that directly affect health. Delaware, New York, and Vermont governors expressed concerns about the use of tobacco products by youth. Other governors drew direct connections between homelessness and health, with Hawaii’s governor highlighting that a hospital in his state had become the first in the nation to place medically fragile, homeless patients into housing to promote recovery. Governors in Maine and New Mexico commented on plans to revive their states’ children’s cabinets to support the health and safety of vulnerable children. Rhode Island’s governor characterized gun violence as “one of the most disturbing and preventable public health crises of this generation” and New Mexico’s governor is requesting that the state’s Department of Health study gun violence to help inform gun violence prevention reforms. Other governors (CA, HI, ME, MI, NM, NY, UT, VT, WA, and WI) commented on environmental issues affecting health, with a few noting the connection between climate change and health, and others committing to improve air or water quality to reduce the negative health effects of pollution. California’s governor also established a state surgeon general position to help address health disparities (see this NASHP blog for more information).
Culture of Health
Eight governors mentioned the importance of building healthy communities, commenting that promoting population health helped create healthy economies. In a future analysis of the governors’ speeches, the National Academy for State Health Policy (NASHP) will provide a more detailed look at how states are specifically addressing and/or tackling some of the social determinants of health — defined as the social and economic factors that directly affect health.
NASHP will track these proposals as they move toward implementation by state legislatures. Clearly, health policy is in play in the states and NASHP will continue to report on state initiatives on a range of health issues in the coming year.
*For some states, information from both a governor’s inaugural address and a state of the state or budget address is included in this review. For other states, information from only one speech is incorporated, due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred; the inaugural address served as the governor’s primary policy speech and no state of the state address is planned; or the governor did not have an inauguration and only had a state of the state address. As of mid-February, 2019, Louisiana and North Carolina governors had not made speeches.