July | August 2017







Five Questions with Debra Miller,
CSG director of health policy

By Lisa McKinney, CSG communications associate
In this occasional series featuring a CSG staff expert, Debra Miller, The Council of State Governments' director of health policy, discusses health care spending and funding, the social determinants of health, the opioid epidemic, and prescription drug costs.

What are the most important health policy issues facing state leaders today?
When I speak to leaders, the issue of health care costs always comes up. Paid out of the states' budgets are several major health insurance programs: the states' required match for Medicaid, now the nation's largest health insurance program, as well as the employer's share for state employees' health insurance and for retired state employees. States also fund other health services including behavioral health and substance abuse treatment, children's health and broader community public health programs. While states strive to improve health outcomes—to actually have healthier residents who they know in the long run will be more productive citizens—they can't wait for savings down the road. Health competes with other state funding priorities as states cope with slow revenue growth coming out of the Great Recession. 

The U.S. spends more on health care than most other industrialized nations but has inferior health outcomes. What are some factors that contribute to this and how can state leaders work to reverse these statistics?
Dr. Michael Williams, surgeon and health care expert from the University of Virginia, who spoke to the CSG Health Public Policy Committee at the 2016 National Conference, told us that our armed forces couldn't fill its ranks because young men and women aren't healthy enough for service. The U.S. spent $8,713 per capita on health care, according to 2015 World Health Organization statistics, compared to the average for advanced nations of $3,425, yet U.S. health outcomes consistently rank in the bottom third of those nations.
The problem isn't health care but what Williams and other experts call the social determinants of health. Our overall health is only influenced 10 percent by health care. More powerful influences are individual behaviors (40 percent) and social and environmental factors (20 percent). These are called social determinants of health and state leaders can do much in these arenas.
The healthy communities movement is one important strategy, where leaders work to build a culture of health and encourage a wide range of health opportunities, including access to healthy food options, physical activity, and clean water and air. Educational achievement influences health, so good schools are another health strategy for state leaders.
Becoming aware of health disparities, where health outcomes on average differ for groups of people based on factors such as race, gender or socioeconomic status, can help state leaders craft strategies to build health for all communities. Relatively new geospatial mapping can be helpful to pinpoint communities with problematic health data and build place-based strategies for improvement.

Drug overdose deaths in the U.S., which surpassed 50,000 in 2015, now exceed deaths from car crashes, according to the Centers for Disease Control and Prevention. What are some of the most effective policies being enacted in states to combat the opioid epidemic?
States are on the front line of the fight against the rapidly increasing opioid epidemic. State leaders are moving quickly on a number fronts. The number of treatment programs is growing. States are paying attention to the research on the effectiveness of medication-assisted treatment, or MAT, that uses medication combined with behavioral therapy and social supports to combat addiction to opioids. Including substance abuse treatment in insurance essential benefits and expanding Medicaid eligibility have opened treatment options to more individuals.
Prescription drug monitoring programs, now in place in all states except Missouri, can provide important information to combat the epidemic of prescription opioid abuse. Half of opioid overdose deaths involve prescription drugs, according to the CDC. States are passing laws to require prescribers to check registries more often, preventing drug-seeking behavior. Florida documented a significant drop in duplicate prescriptions after adopting such a law.
Many states are adopting strategies that lower the likelihood of deaths from overdose, including broader access to naloxone, a medication administered to reverse an overdose. Addicts and families can have access without specific prescriptions. First responders carry naloxone and 911-callers are provided immunity from prosecution to encourage intervention in overdoses.
Syringe exchange programs reduce health risks to those who abuse drugs as well as law enforcement personnel who often suffer needle sticks in the line of duty. These programs can be important referral sources for drug abuse treatment.

States, as providers of health insurance to employees, retired employees, Medicaid enrollees and prison populations, are concerned about the high cost of prescription drugs. What strategies are states exploring to control these costs?
The cost of prescription drugs troubles state leaders and consumers alike. States (as well as major insurers) are using benefit management strategies, rebates and cost-effectiveness research to reduce prescription drug costs while allowing patients access to life-saving drugs. Other health management strategies also work to strengthen drug effectiveness, and thus prevent wasteful spending, by encouraging compliance with prescription drug regimens. Some states are exploring laws that open transparency on drug pricing even though savings might be difficult to achieve.

The first try to repeal and replace the Affordable Care Act during President Donald Trump's administration did not make it across the finish line. What should state leaders be looking at as the issue continues to percolate?
The first generation proposal under the Trump administration to repeal and replace the Affordable Care Act would have resulted in $880 billion less in federal Medicaid funding to states in the next 10 years, according to the Congressional Budget Office estimate. States are unlikely to be able to make up that funding from their own state revenues. Even with increased flexibility and less burdensome federal regulations, states may be forced to cut services or reimbursement rates.
States that expanded Medicaid eligibility will want to watch how a new proposal may provide for a different matching formula than the 90 percent federal match in the ACA. States will also want to watch how newly eligible enrollees are funded compared to continuously enrolled persons.