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.