By Jennifer Horton
Location can be crucial in determining a patient’s experience with the U.S. health care system. For example, residents of Texas are six-times more likely to be uninsured than those living in Massachusetts. In Utah, the rate of premature death from preventable causes in adults under 75 is half that of West Virginia.
The Commonwealth Fund’s Scorecard on State Health System Performance, which provided the aforementioned data, assesses state performance across several measures, including overall health outcomes, access and affordability, and prevention and treatment. The 2022 scorecard was the first to assess the impact of the COVID-19 pandemic on Americans’ health.
While all states suffered, the impact of COVID-19 depended on how stable a state’s public health foundations were before the pandemic began. States with stronger health systems, indicated by low uninsured rates, strong primary care capacity and effective care management, experienced lower rates of preventable deaths due to COVID-19 and had healthier populations. The health of a population is marked by rates of premature death, health status, health risk behaviors and other factors.
To address health care deficits — some that predated the pandemic and those that were created by it — states are taking a wide variety of policy approaches, including expanding access to care, improving maternal health outcomes, reducing the cost of prescription drugs and expanding direct care.
Access to Care
Opponents of Medicaid expansion object to the lack of a work requirement for eligible parties and worry an expansion could impact a state’s budget, among other concerns. The federal government covers 90% of the cost of Medicaid coverage for adults under the expansion, leaving states to pay the remaining 10%. The American Rescue Plan Act of 2021 offered states an additional fiscal incentive to implement the expansion by increasing the federal match to 95% for two years, an estimated net benefit of $9.6 billion to the eligible states, but no states accepted the offer. Proponents pushed back on economic concerns caused by the potential influx of federal dollars on local economies, citing analyses conducted by expansion states suggesting the expansion actually reduced total state spending.
In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level and provided states with an enhanced federal matching rate. As of December 2022, all but 11 states had adopted the expansion. An analysis by the Kaiser Family Foundation revealed states that adopted the expansion experienced budget savings, revenue gains and overall economic growth. Research indicated the expansion also improved access to care, affordability, utilization of services and led to coverage gains and reductions in the number of uninsured citizens, particularly among low-income and vulnerable populations.
While the debate continues, several states took action to expand Medicaid or make enrollment easier:
- In January 2016, Gov. John Bel Edwards signed executive order JBE16-01, instructing the Louisiana Department of Health and Hospitals to expand Medicaid to adults who are ages 19-64, have an income less than 138% of the federal poverty rate, do not already qualify for Medicaid or Medicare, and meet the citizenship requirement. The state’s Medicaid Expansion Dashboard compiles data on the order’s impact on residents and access to health services.
- Maryland Senate Bill 802 (2019) established the Easy Enrollment Program, allowing state residents to indicate their interest and facilitate enrolling in Medicaid, the Children’s Health Insurance Plan or subsidized exchange coverage by checking a box on their tax return.
- Utah House Bill 3 (2022) directed $3 million to establish the One Utah Health Collaborative, an initiative designed to reduce health care costs, improve health outcomes, close gaps in health care and improve quality of life through a public-private partnership centered on patient needs.
- Washington Senate Bill 5526 (2019) established “Cascade Care,” a semi-public option health care plan offering premium subsidies to allow individuals whose incomes are less than 500% of the federal poverty level to purchase individual market coverage on the state health benefit exchange.
Roughly 700 women die each year from pregnancy-related causes in the U.S., resulting in the highest maternal mortality rate among all developed countries. In 2018, the latest available year of data, the national average was 17.3 pregnancy-related deaths per 100,000 live births. But the averages cover up crucial differences in sub-populations: Black people are three times more likely to die in childbirth than white people. Some states have taken steps to address racial disparities in maternal mortality rates:
- California Senate Bill 464 and Maryland House Bill 837 require health care professionals involved in perinatal care to undergo an evidence-based training program.
States have approached improving the maternal mortality rate from a variety of angles, including doula care, home visiting programs and workforce training.
Research shows pregnant people who receive doula care are more likely to have healthy birth outcomes and positive birth experiences. Medicaid reimbursement for doula services can increase access to health care and strengthen birth outcomes for Black people experiencing pregnancy.
- Minnesota (SPA 14-07, 2014), New Jersey (SPA 20-0011, 2021), Oregon (SPA 17-0006, 2017) and Virginia (SPA 21-0013, 2021) reimburse doulas as an optional Medicaid benefit. A chart summarizing the components of each state’s Medicaid doula benefits can be viewed here.
Home visiting programs, which helps deliver babies and connect pregnant people and new parents to social, health and educational services, are another strategy for improving health outcomes. Studies show the programs can reduce child abuse and domestic violence and improve maternal and child health outcomes while also delivering long-term cost savings. Federal funding is available to support home visiting services in the U.S., with at least 20 states using Medicaid to support their programs.
- New Jersey Senate Bill 690 and Oregon Senate Bill 526 established voluntary statewide home visiting programs providing free services to support healthy child development, strengthen families and provide parenting skills.
Prescription Drug Pricing
At least twenty states have enacted co-payment caps to reduce the cost of insulin, with most caps only applying to people with private insurance. Minnesota is one of the only states with a co-payment cap for the uninsured and requires insulin manufacturers to provide universal discounts. Other states take different approaches to help make prescription drugs like insulin more affordable, as shown in Table 1 below.
State Actions To Make Prescription Drugs More Affordable
|Bill or Action
|House Bill 249
|Required a health benefit plan that provides coverage for prescription insulin to cap the total amount of any cost sharing or co-payment, without regard to the policy deductible, regardless of the amount or type of insulin needed.
|Allocated $100 million to launch an effort allowing the state to contract and make its own insulin at a lower price.
|House Bill 119
|Formalized the legal process for donating unused prescription drugs to certified pharmacies or health departments for reuse by eligible populations.
|House Bill 95
|Capped the cost-sharing requirements for prescription insulin.
|Senate Bill 165
|Required health benefit plans that cover prescription drugs and use a specialty drug tier to cap copayments or coinsurance.
|House Bill 761
|Capped copayments and coinsurance for specialty prescription drugs.
|House File 3100
|Created the Insulin Safety Net Program, allowing eligible individuals to receive a free 30-day supply of insulin in an emergency and caps the insulin copayment for a 90-day supply at $50.
|House Bill 1019
|Capped cost sharing for a 30-day supply of covered prescription insulin. The bill also requires insurers to provide coverage for equipment and supplies for the treatment and management of diabetes.
Direct Care Direct Care Workers, a broad umbrella term that includes personal care aides, home health aides and nursing assistants, who support older adults and people with disabilities, comprise the largest workforce in most states and provide essential support to millions of people in a variety of settings. Currently, both a worker shortage and an inability to meet the growing demand for long-term services and support hinders the field’s growth. States approach the long-term care crisis from a variety of angles:
- New Jersey Senate Bill 3847 (2020) established a program allowing a family member or approved individual of an enrollee in Medicaid or NJ Family Care who is under 21 years old to be certified as a certified nursing assistant and provide services to the enrollee under the established reimbursement rates.
- Washington state’s Long Term Services and Supports Trust Act (2019) established the WA Cares Fund, a long term care insurance benefit for all eligible Washington state residents to address the future long-term care crisis. The law provides individuals with access to a lifetime benefit amount up to $36,500.
- National Conference of State Legislatures Prescription Drug State Bill Tracking Database
- NCSL Health Innovations State Law Archive Database
- National Academy for State Health Policy: State Legislative Action to Lower Pharmaceutical Costs
- NCSL Health Care Policy Toolkit for State Legislators