1. 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

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

3. 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 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.”

4. Public Health

5. Public Health

6. 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

7. Medicaid as % of Total Expenditures, 2016
State
State General Funds, 2016
Medicaid as % of Total Expenditures, 2016
% Change State Funds,
Missouri
$2,033 M
37.2
5.4
Iowa
$1,405 M
22.6
3.8
Nebraska
$ 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 in Nebraska to in Missouri (Kansas and Iowa 56.74)
Source: National Association of State Budget Officers, State Expenditure Report,

8. 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

9. 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

10. 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

11. 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 ( ) 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

12. 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

13. Contact Information
Debra Miller, Director of Health Policy
The Council of State Governments
1776 Avenue of the States
Lexington, KY 40511