Health Policy & Advocacy in Changing Times The Council of State Governments (CSG) Health Policy & Advocacy in Changing Times Debra Miller Director of Health Policy The Council of State Governments MINK Conference, Overland, KS April 18, 2017

Big Health Issues for State Policymakers Health care costs Medicaid budget Medicaid expansion The uncertain future of the Affordable Care Act and any replacement

The Health Care Context Health spending is currently 17.8 percent GDP Health care (19%) # 3 priority after economy and jobs (24%) and immigration (20%) in Jan. 2017 Kaiser Health Poll Medicaid alone is first or second biggest state budget item U.S. spends more and has worse outcomes than other Western nations When presented with two general approaches to the future of health care in the U.S., six in ten (62 percent) Americans prefer “guaranteeing a certain level of health coverage and financial help for seniors and lower-income Americans, even if it means more federal health spending and a larger role for the federal government” while three in ten (31 percent) prefer the approach of “limiting federal health spending, decreasing the federal government’s role, and giving state governments and individuals more control over health insurance, even if this means some seniors and lower-income Americans would get less financial help than they do today.”

Public Health

Public Health

Michael D. Williams, M.D., Director of The Center for Health Policy, The Frank Batten School for Leadership and Public Policy, University of Virginia, and Associate Chief Medical Officer, UVA Health System at CSG National Conference, December 2016 Public Health

Medicaid as % of Total Expenditures, 2016 State State General Funds, 2016 Medicaid as % of Total Expenditures, 2016 % Change State Funds, 2015-2016 Missouri $2,033 M 37.2 5.4 Iowa $1,405 M 22.6 3.8 Nebraska $ 924 M 17.1 7.8 Kansas $1,282 M 22.5 9.2 More Americans insured by Medicaid than Medicare 62% Medicaid is federally funding currently; 38% state funded Varies in MINK states: from 51.85 in Nebraska to 63.21 in Missouri (Kansas 56.21 and Iowa 56.74) Source: National Association of State Budget Officers, State Expenditure Report, 2016. https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/State%20Expenditure%20Report%20(Fiscal%202014-2016)%20-%20S.pdf

Status of State Medicaid Expansion, April 2017 10.7 million new eligibles in 2015; another 3.4 million under “welcome mat” What isn’t debatable is that U.S. uninsured percentage has dropped to its lowest level in history: less than 9 percent from about 16 percent before the ACA

Impacts of Medicaid Expansion “Celebrate” expanded access to insurance Expanded eligibility for behavioral health and substance use disorder Decreased uncompensated care for hospitals Job growth in health services sector and economic “multiplier effects” in communities Early studies: improved health (natural studies of neighboring states); expansion “free” to states (Gruber, MIT, April 2017) Little evidence of improved health outcomes State growth of Medicaid spending slower in expansion states than non-expansion states Best research: literature review by Kaiser Family Foundation, June 2016

Must keep campaign promise to repeal & replace Repeal and Replacement of Affordable Care Act, American Health Care Act, vote delayed: March 2017 Must keep campaign promise to repeal & replace Must pass without Democrats (only 16 Republicans can vote no) Must pass muster with conservative Republicans (no mandate, work requirements, free market principles, deficit reduction) Must pass muster with more moderate Republicans (maintain expansion & state funding) Must stop/reverse increase in individual premium costs 85 % buying individual insurance are shielded from premium increase by ACA subsidies About 3-5 percent Americans buy individual policies without any help to keep them affordable

Urban Institute State by State Analysis CBO Analysis of AHCA 24 million Americans would lose health coverage $880 billion federal Medicaid funding lost to states under per capita caps Urban Institute State by State Analysis States Medicaid Cut (2019-2028) if states cut all funds proportionate to federal cut Missouri $5 billion, 3.4 % cut Iowa $6 billion, 9.8 % cut Nebraska $1 billion, 3.3 % cut Kansas $2 billion, 3.4 % cut Source: Urban Institute, The Impact of Per Capita Caps on Federal and State Medicaid Spending, March 2017. http://www.urban.org/sites/default/files/publication/89061/2001186-the_imapct-of-per-capita-caps-on-federal-spending-and-state-medicaid-spending_1.pdf

Trump “skinny” budget for FFY 2018 Total: $15 billion cut (-18 %) to Dept. of Health and Humans Services ($69 B request) $6 B (-19%) cut in National Institutes of Health $4.2 B cut in Office of Community Services $500 M increase for opioid abuse prevention $500 M increase for CDC grants to states for flexibility for leading public health issues Pundits: “DOA” Must balance out increase of $54 billion in military spending

Contact Information Debra Miller, Director of Health Policy The Council of State Governments 1776 Avenue of the States Lexington, KY 40511 859-244-8241 dmiller@csg.org www.csg.org