Alan Weil Executive Director National Academy for State Health Policy December 2006

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Alan WeilExecutive DirectorNational Academy for
State Health PolicyDecember 2006
Exhibit 1
Role of States in Health Policy
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All Levels of Government are Involved in Health
Policy
Exhibit 2

• Federal
• Department of Health and Human Services
• Agencies include CMS, NIH, CDC, HRSA, FDA, AHRQ,
  SAMHSA
• Programs include Medicare, Medicaid, SCHIP, MCH,
  Family Planning

• State
• Departments of Health, Human Services or Social
  Services
• Divisions of Insurance
• Medical Schools Affiliated Teaching Hospitals

• Local
• Departments of Public Health

3
Spending on Health Accounts for a Sizable Share
of State Spending Half from Federal Funds
Exhibit 3
Federal Funds
Non-health Expenditures 70
50
Health Expenditures 30
General Fund
38
Other State Funds
12
Total U.S. State Health Spending 1.1 Trillion
Source Milbank Memorial Fund, The National
Association of State Budget Officers, andthe
Reforming States Group, 20022003 State Health
Expenditure Report, June 2005
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Exhibit 4
The Social, Political, and Economic Climate
Varies Considerably from State to State
State government tax collection per capita, 2004

• Variation in political traditions, fiscal
  capacity, tax rates, priorities of states

• Largely differing demographics and health needs

• Large disparities in state capacity to respond
  to needs

Less than 1,800
1,800 to 1,999
2,000 to 2,200
More than 2,200
Source State Government Tax Collections 2004,
U.S. Bureau of the Census, available at
http//ftp2.census.gov/govs/statetax/04staxss.xls.

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States Play Multiple Roles in Health Policy
Exhibit 5

• Regulator

• Purchaser

• Provider

6
States Have Major Role as Health Care Regulators
Exhibit 6

• Health care professional licensing
• - Doctors, nurses, psychologists, dieticians, etc.

• Health facility licensing
• - Hospitals
• - Nursing homes

• Insurance company and managed care organization
  regulation
• - Pricing and benefits
• - Market conduct
• - Financial solvency

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Exhibit 7
Regulating Health Care Providers
Advanced practice nurse prescriptive authority by
state, 2005
State allows AP Nurses to prescribe
Only non-controlled substances with some MD
involvement
All substances with some MD involvement
All substances independent of MD involvement
Source Pearson, L, 16th Annual Legislative
Update How Each State Stands on Legislative
Issues Affecting Advanced Nursing Practice, 2005.
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Exhibit 8
Regulating Private Insurance
State mandated benefits Mental health parity,
2004
State mandates some level of mental health parity
Source Health Policy Tracking Service, a service
of Thomson West, November 2005, available at
www.netscan.com.
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States Purchase Health Care for Certain
Populations
Exhibit 9

• Medicaid beneficiaries

• Children covered by SCHIP

• State employees retirees

10
Medicaid Dominates State Health Spending
Exhibit 10
Medicaid72
Source Milbank Memorial Fund, The National
Association of State Budget Officers, andthe
Reforming States Group, 20022003 State Health
Expenditure Report, June 2005
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Medicaid Basics
Exhibit 11

• Medicaid is administered by the states with
  federal oversight and shared federal/state
  financing (57 federal)

• Medicaid provides health and long-term care
  services for over 52 million low-income people
• 39 million adults children in low-income
  families
• 13 million frail elders and people with
  disabilities, including over 6 million Medicare
  beneficiaries

• Pays for nearly 1 in 5 health care dollars and 1
  in 2 nursing home dollars

• Large variation across states in eligibility and
  scope of benefits

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Exhibit 12
States Make Very Different Policy Choices in
Running Their Medicaid Programs (within Federal
Guidelines)
Medicaid income eligibility threshold for working
parents, 2005
lt40 FPL
40 to 69 FPL
70 to 110 FPL
gt110 FPL
The federal poverty level (FPL) was 19,350 for a
family of four in 2005. Source Health Policy
Tracking Service, a service of Thomson West,
November 2005, available at www.netscan.com.
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Exhibit 13
State Spending on Retirees Benefits is Rising
California Expenditures on Health and Dental
Benefits for Retired State Employees, 1997 to
2007

(In Millions)
Source Legislative Analysts Office, CA,
February 17, 2006.
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Exhibit 14
Some States Are Taking Leadership Roles in
Expanding Coverage to Their Uninsured

• Incremental expansion efforts at state-level

• Most efforts focus on covering children or
  parents, usually with Medicaid/SCHIP
  expansions

• A few states have tried employer mandates with
  varying levels of success

• Some states allow public funds to be used to
  purchase private insurance for uninsured

• Massachusetts uses combination of approaches that
  includes individual mandate, subsidies for
  low-income, and public insurance that uninsured
  can purchase.

• Recent efforts in MA, ME, MD, IL

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States as Health Care Providers
Exhibit 15
States provide medical services directly through

• Facilities for the developmentally disabled and
  mental health hospitals

• State-operated nursing homes veterans homes

• Prisons

• Medical schools affiliated teaching hospitals

• Public and Population Health

• Programs for Targeted Populations

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Prison Health Expenditures Are Mounting as Number
of Inmates Rise and Age
Exhibit 16
Health Care,12
State prison expenditures by expense, 2001

• Over 2.1 million prisoners in U.S. In 2005, -
  about 1 prison inmate for every 205 residents

Health Care, 12

• States spent 4.0 billion on inmate medical care
  in2003

Food, 4
Capital Improvements, 4

• Increase in spending result of larger prison
  population, increase in HIV/AIDS, and aging of
  prison population

Salaries, Wages and Benefits of Prison
Employees, 66
Other, 14
Source US Department of Justice, State Prison
Expenditures, 2001.
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State Medical Schools The California System
Exhibit 17

• Training grounds for new medical workers

• University of California is the nations largest
  health science and medical training program, with
  over 12,000 students enrolled annually

• Large providers of medical services

• UC medical centers operate 3,600 hospital beds
  and receive over 120,000 inpatient discharges and
  239,000 emergency room visits and 3.3 million
  outpatient visits a year

• Important service providers to low-income
  populations

• UC medical centers are the second largest
  provider of Medicaid services in California, 56
  of UC hospital patient days were paid through
  Medicaid and Medicare programs

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States Provide Important Public Health Services
to the General Population
Exhibit 18
Public health functions

• Disease surveillance

• Vital statistics records and reporting

• Staff and operate pathology labs

• Injury prevention and public safety

• Medical research

• Protection against environmental hazards

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States Also Run Other Health Services Often
Financed with Federal Funds
Exhibit 19

• Title V

• Title V
• Maternal and Child Health Program
• Drug assistance for seniors
• Chronic disease hospitals and programs
• Hearing aid assistance
• Adult day care for persons with Alzheimers
  disease
• Health grants
• Medically handicapped children
• Women, Infants, and Children (WIC) programs
• Pregnancy outreach and counseling
• Chronic renal disease treatment programs
• AIDS treatment
• Breast and cervical cancer screening and
  treatment
• Tuberculosis (TB) programs
• Emergency health services
• Adult genetics programs
• Phenylketonuria (PKU) testing

• Services under state purview include

• Maternal and Child Health Program

• Breast and cervical cancer screening and
  treatment

Source Milbank Memorial Fund, The National
Association of State Budget Officers, andthe
Reforming States Group, 20022003 State Health
Expenditure Report, June 2005
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Public Health Preparedness Funding Has Grown
Exhibit 20
Preparedness funding to states from Federal
grants 1999-2004, in Millions of dollars
1,368
1,347
1,043
Source The Commonwealth Fund, State Preparedness
for Bioterrorism and Public Health Emergencies,
2004
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The Relationship Between Federal and State
Governments is Constantly Changing
Exhibit 21

• Periodic efforts to replace individual state
  regulation with consolidated regional or national
  regulations

Provider Regulation
Insurance Regulation

• Health Insurance Portability and Accountability
  Act (HIPAA) created first federal standards for
  health insurance

• Association Health Plans (AHPs) New class of
  federally-regulated health plans

• Efforts to preempt state coverage mandates

• Deficit Reduction Act of 2005 and waiver
  programs give more authority to states

Medicaid
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Conclusions
Exhibit 22

• States are involved in healthcare as regulators,
  purchasers and providers

• States are at the forefront of efforts to cover
  the uninsured, but face many barriers and
  progress is slow

• Renewed federal interest in pre-empting
  traditional state authority regarding insurance
  regulation may impede action

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Additional Resources

• Kaiser Family Foundation (KFF) Statehealthfacts.or
  g
• National Academy for State Health Policy (NASHP),
  Making Medicaid Work for the 21st Century
• NASHP, Patient Safety and Medical Errors A
  Road Map for State Action
• KFF, National ADAP Monitoring Report
• Kaiser Commission on Medicaid and the Uninsured,
  State Fiscal Conditions and Medicaid
• National Governors Association, State-Funded
  Home and Community-based Service Programs

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