In November, US voters across the country will face decision time as they head to the polls. Between the 36 gubernatorial races, 36 Senate races, and all 435 seats of the House that are up for election, it’s hard to miss the campaign commercials and fliers that have come our way and will continue to do so right up to election day. But voters aren’t the only ones who face decision time. Many governors and state legislatures are weighing their options for where to spend precious resources with respect to their health care priorities.
Since the Affordable Care Act (ACA) passed in 2010, there have been many revisions, delays and even permanent removals of certain provisions of the law. These changes in legislation and regulation have brought significant decisions to states’ front doorsteps. Many of these have been covered extensively in the news, and in some states, are as hotly debated as (or sometimes even inserted into) the elections themselves. To date, 28 states and the District of Columbia have made the decision to expand their Medicaid programs.1 Similarly, states have faced decisions around their health insurance marketplace operations—more than half have defaulted to the federally-facilitated model, while the remaining states are either implementing state-based marketplaces or working in conjunction with the federal government in a partnership model.2
Other health care issues states have faced are not as well known or widely publicized—these are the issues that have yet to make the headlines. But as we quickly head toward the end of 2014, many states are grappling with some big decisions in health care:
- State-based health insurance marketplaces: In the future, where will funds to sustain operations come from? Given the dual aim of re-enrolling last year’s enrollees and signing up new enrollees, how should spending on outreach and in-person assistance for the second round of open enrollment be focused?
- Small Business Health Options Program (SHOP) marketplace: What is the status of the SHOP marketplace in the state and how does that map against the federal government’s efforts? Where should resources be spent to increase employer awareness and understanding?
- ICD-10 delay: How are individual states and their Medicaid programs mapping to the updated plans? Are mid-course adjustments needed?
- Provider network standards: Should provider network standards be stricter or more lax? How should the state work with health plans and providers to refine network standards?
These decisions and others are difficult for states to make, especially as budget constraints continue to increase, legislative mandates loom and consumer demand grows. Meanwhile, populations are aging, fewer are entering into the physician workforce and outdated technology infrastructures are lagging in interoperability, security standards and analytics capabilities.
There is not a “one-size-fits-all” solution for states as they contemplate these tough health care decisions. As decision makers determine how they want to position their states for the future, the following three paradigms, in my opinion, will be critical considerations:
Adapt the role of the state to promote innovation: As providers, payers, regulators, and collaborators, states should seek to use their influence and authority to innovate and drive population health management. States can encourage public and private players across the health care system to work together to achieve better outcomes and value. This involvement will be critical, and state decision makers should consider their state-wide population as a whole as well as the individual needs of specific communities based on socioeconomic factors and social determinants.
State-based health insurance marketplaces can be structured so that, as a regulator, the state can help providers and plans react and adjust to increased consumer demand for quality and affordable health insurance and health care. Outreach can also be tailored at the state level to specific groups and hard-to-reach populations. In Washington, DC, for example, workers from the state-based marketplace, DC Health Link, canvassed local laundromats to help residents enroll in health insurance while their clothes were drying.3
Build a 21st century connected infrastructure to enable transformation: Reliance on technology will continue to grow, further necessitating interoperability between electronic health records (EHR) systems, Medicaid Management Information Systems, all-payer claims databases, health information exchanges (HIE), integrated eligibility systems, and state health insurance marketplaces. With the explosion of mHealth, building an infrastructure that connects all the dots between technology and people becomes even more important. States occupy an important position at the epicenter of the infrastructure to help drive transparency and transformation through integration.
For example, established in 2003 as an independent state agency, Maine’s all-payer claims database allows stakeholders across the health care system to access critical information on medical, pharmacy, and dental claims and information from commercial health plans, third party administrators, Medicaid and Medicare. The state’s Maine HealthCost website also provides health care consumers transparency around health care prices such as the average cost of certain medical procedures. States can enhance their role in making information available to individuals as stakeholders in the system aim to help individuals move from passive patients to informed health care consumers.
Unleash the power of data to drive outcomes: Population health can be within reach if states help influence data sharing behavior and support integration efforts among all stakeholders. Once this is achieved, states will be in a unique position to educate and empower health care consumers.
The Centers for Medicare & Medicaid Services (CMS) and others are focused on finding ways to reduce costs and improve quality. For example, earlier this month CMS released its latest figures on hospital readmissions, announcing that more than 2,000 hospitals across the country would be penalized with reduced Medicare reimbursement for high readmissions in their patient populations. States are working to help reduce high readmission rates by implementing certain population health strategies. Data from Kentucky’s state Medicaid program were integrated with data in the state’s HIE to identify “super-utilizers” of the emergency departments statewide. Now, when a super-utilizer patient returns to the emergency department, their medical record is flagged and the provider is sent an alert.
As voters educate themselves on candidates’ platforms for the election, they are likely to take a keen eye to how the state is performing on important issues. Some issues come up in every election—economic and social factors can make or break a candidate. As state decision makers and legislators begin to take on greater responsibility for the health and care of their populations, voters are likely to increase their focus on health care, especially state health policy decisions that affect them, their families and their wallets.
1 See Deloitte’s State Medicaid programs: Map of expansion by state
2 See Deloitte’s Health insurance exchanges: Map of enrollment by state
3 DC Health Link, “DC Health Link Says: As You Spring Clean, Start With a Clean Bill of Health and Get Affordable Health Insurance,” March 20, 2014