Palliative care webinar offers opportunities to improve life for seriously ill people — and save money

Our recent webinar with Dr. Diane Meier from the Center to Advance Palliative Care was moving as well as offering a very promising policy option for state Medicaid programs. Palliative care offers great potential to improve and extend the lives of people with serious illness, allowing them to get care at home if they wish, while controlling costs. Click here to watch a video of the webinar and here for the slides.

Insurance exchange premium growth in ERC region averaged 6.7% this year with wide variation; same variation but higher prices expected for 2017

A new analysis finds that insurance exchange premium growth over the last two years varied considerably between states. According to the Urban Institute, the average annual premium increase for the lowest cost Silver plan from 2014 to this year was 5.5% nationally and 4.2% for the ERC region. However individual ERC state annual rates varied considerably from New Hampshire where premiums dropped 5.1% on average to Delaware where premiums grew by 11.2%. This year ERC state premiums are higher than other regions, averaging $307/month for the lowest cost Silver plan; 8.4% higher than the US average. Vermont has the highest premiums in the region; Maryland and Pennsylvania are tied for lowest.


Premiums may jump far higher next year, according to new report by Avalere. Their analysis of proposed rate filings from the nine states where complete 2017 data is available includes Maryland, Maine, New York and Vermont. The report finds wide variation in premium increases across states, ranging from 5% in Washington to 44% in Vermont for the lowest cost Silver plan. As data is complete for only nine states and these proposed rates are subject to state review and negotiation, averages will likely change before premiums are set. It is also important to note that most consumers are protected from full premium costs with income-based subsidies.

  Average 2016 premium for lowest cost Silver Plan 2015-2016 relative change
CT $351 0.8%
DE 354 19.0
ME 309 0.8
MD 245 7.5
MA 247 1.5
NH 260 9.3
NJ 325 3.3
NY 372 8.1
PA 245 10.5
RI 259 6.1
VT 465 8.6
Northeast region 307 6.7
US average 283 8.3

Awaiting Governor’s signature, VT bill requires drug companies to justify prices

A Vermont bill that would make drug companies justify their prices has passed both houses and awaits the Governor’s signature. S.216 requires drug companies to submit detailed information explaining price increases for the most common drugs with sharply rising prices. The information would be reported publicly online. It is unclear what the state will do with the information, but the bill states, “In order to contain prescription drug costs, it is essential to understand the drivers of those costs, as transparency is typically the first step toward cost containment.” Similar bills have been considered in MA, CA, VA, OR and NC, but Vermont’s bill is the closest to becoming law. The Governor plans to make a decision on the bill by June 9th.


CSG/ERC’s Health Policy Committee will explore state/provincial options to control drug prices at the Annual Meeting this August in Quebec City. Click here for more information and to register

CSG/ERC Seminar at Penn Addresses Carbon Policies, Sustainable Water Infrastructure and Renewables

On May 6, CSG/ERC brought together legislators from around the Northeast and eastern Canada to discuss policies to reduce carbon emissions, expand access to renewable energy and electric vehicles and promote sustainable practices for managing urban water resources.

The meeting was hosted by the Kleinman Center for Energy Policy at the University of Pennsylvania, and allowed participants to share strategies for addressing a range of common policy goals, and discuss opportunities for collaborative approaches.

Mark Alan Hughes, faculty director of the Kleinman Center, provided an overview of the international climate accord completed in Paris last December, which was signed by the U.S. and nearly 180 countries last month. The accord marks the first time the global community has consented to a target for cutting planet-warming emissions. The historic agreement seeks to limit the rise in Earth’s temperature to 2 degrees C (3.6 degrees F) above pre-industrial levels. In reality, though, most scientists agree that the targeted cuts are not sizeable enough to prevent temperatures from exceeding that threshold, which creates greater urgency for the international community to accelerate their efforts to keep warming in check.

Hughes, the former sustainability director for the city of Philadelphia, discussed the collective action problem that economists often cite in relation to carbon policies: Almost all of the benefits of climate reductions tend to flow those residing outside of the location where those cuts were made. On a global scale, he noted, more than half of the pledges contained in the Paris agreement require actions among state and local governments to limit carbon emissions. He advised that officials in those “subnational” bodies focus on local strategies that will assist their economies the most, because often, they will produce the biggest net benefits for local populations, and the environment.

For example, policies driven by indigenous goals, like limiting harmful pollution to reduce respiratory-related illnesses and enhance human health, will likely lead to deeper emissions cuts than policies focused solely on climate benefits. Efforts to enhance building codes to encourage greater energy efficiency, or programs encouraging electricity system resiliency, like microgrids, are designed to yield immediate, tangible benefits, and tend to encourage greater enthusiasm, and compliance, Hughes said.

In recent years, 16 states — including nine in the Northeast — and 35 cities have resolved to lower their greenhouse gas emissions 80% from a 2005 (or lower) baseline by 2050. Hughes noted that despite these shared goals, it is probably not efficient to require that every state and urban center meet the same global target, given that local conditions will dictate the most effective strategies for making emissions cuts.

At the federal level, the Obama administration has devised policies intended to help meet a goal announced last year of cutting national emissions 26-28% below 2005 levels by 2025. The U.S. Environmental Protection Agency’s Clean Power Plan, which calls for a 32% reduction in carbon emissions from the nation’s power plants by 2030, is intended to help achieve that target. The rule was finalized last year, but in February, it was stayed by the Supreme Court pending judicial review. Other policies include increased vehicle fuel efficiency for cars and trucks, which will rise to 54.5 miles per gallon in 2025 under rules issued in 2012. It is generally understood that even if the Clean Power Plan is upheld by the Court, additional federal, state and local policies will be needed to meet the nation’s reduction goals.

During the meeting, participants discussed legislation that has been introduced at the state level, including revenue-neutral carbon pricing bills in Massachusetts and Rhode Island. The bills would levy a fee on fuels that emit carbon dioxide, and rebate 100% of the proceeds equally to all households. Both states participate in the nine-state Regional Greenhouse Gas Initiative (RGGI), which caps emissions from power plants that generate 25 megawatts or more of electricity.

Massachusetts State Senator Michael Barrett, who sponsored one of the proposals, S. 1747, noted that 80 percent of carbon emissions in the state come from cars and trucks, which are not covered by RGGI. His bill is intended to help Massachusetts meet the targets contained in the 2008 Global Warming Solutions Act, which calls for reducing economy-wide carbon emissions 25% below 1990 levels by 2020, and 80% by 2050.

Click here to view a presentation on the “Economic Impacts of Carbon Fees at the State and Local Level” from Scott Nystrom, Senior Economic Associate, REMI, Inc.)

Treating Water as a Sustainable Commodity

Participants also heard from former Philadelphia Water Commissioner Howard Neukrug, who addressed what he considers to be the biggest environmental problem in the U.S. today: the overflow of rainwater from impervious surfaces into our sewers.

“The challenge is that the world takes rainwater and doesn’t make it into a commodity—it has no value – and treats it as wastewater,” said Neukrug, who is currently a senior fellow at the US Water Alliance and a fellow at the Penn Institute for Urban Research.

As landscapes become increasingly urbanized, they are characterized by the steady replacement of pervious surfaces with impervious ones – e.g., asphalt roads cover former forests and farmland – leading to increased stormwater runoff and combined sewer overflows. Rainfall that once filtered through the soil gets funneled along manmade surfaces into underground sewers and dumped into waterways used for recreation and drinking water, picking up pollutants along the way.

The bottom line, said Neukrug, is that investing in a landscape-based approach to stormwater management, through the use of green infrastructure, offers a more cost-effective, environmentally friendly, and sustainable method for managing water resources compared with conventional “gray infrastructure” practices that favor expensive investments in tunnels and sewers. Tools include stormwater planters, green roofs and rain gardens that soak up some of the runoff and filter pollutants before the remaining stormwater flows into sewers.

Neukrug explained how the internationally acclaimed Green City, Clean Waters Plan that he developed for Philadelphia is helping the city comply with the Clean Water Act, and saving more than $5 billion that would have been spent on building pipes, tunnels and storage basins. The program is eventually expected to reduce the stormwater pollution flowing into local waterways by 85%.

“We’re looking at this as a major positive change for how Philadelphia is managing its water resources for several centuries to come,” he said.

During a roundtable discussion, participants also discussed efforts to broaden access to renewable energy in their states, through legislation to raise New Hampshire’s net-metering cap, a proposal to make solar power in Maryland cost-effective for low-income communities, and a recent agreement between investor-owned utilities in New York and solar companies to revise net metering for solar installations. Net metering is the compensation system that credits owners of solar installations for the excess power that they generate and sell to the grid. They also heard about Québec’s aggressive policies to promote an infrastructure for electric vehicles and to decarbonize the economy.

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New report finds higher access to care in ERC states

Despite wide state-to-state variation, a new CDC report finds that in 2014 residents of all ERC states are more likely to have a usual source of medical care than most Americans. Vermont led the country with only 2.8% of residents that report they do not have a regular care site. Vermont also leads the country in the percent of residents who’ve seen or talked to a general doctor in the last year at 84%. ERC states also performed well on this metric. Interestingly, the study found little impact on these metrics of states’ decisions to expand Medicaid or create a state-based health insurance exchange.

State Adults without a usual place of medical care Adults who’ve not seen a general doctor in 12 months
Connecticut 10.1% 29.6
Delaware 6.8 18.4
Maine 12.6 31.2
Maryland 14.6 30.6
Massachusetts 7.5 28.5
New Hampshire 11.6 27.6
New Jersey 15.9 34.7
New York 12.1 31.0
Pennsylvania 12.7 26.4
Rhode Island 10.1 28.5
Vermont 2.8 15.9
US average 17.3 34.0

Wide variation in health care prices by state

A new report finds that health care prices are higher across most of the CSG-ERC region than the rest of the US. Only New York and Maryland’s prices were below the national average. The report by the Health Care Cost Institute averaged prices for common treatments across and within 41 states and the District of Columbia. Prices between states varied by more than double, but within states prices sometimes varied threefold. Alaska had the highest average prices in the nation; Florida’s prices averaged the lowest. In the ERC region, prices for care in New Hampshire were highest, and Maryland the lowest. Information was not available from nine states, including Vermont. The report found that prices vary for some services more than others; prices for imaging, radiology and lab test prices varied the most. The authors argue that some variation in prices reflects differences in labor and other costs, much variation is driven by market forces such as a lack of price transparency, competitive pressures, or the availability of alternatives.

State Rank Average price for 162 common services, relative to US average
NH 4 1.65
ME 9 1.30
MA 9 1.30
PA 13 1.21
CT 14 1.18
DE 19 1.15
NJ 22 1.07
RI 26 1.02
NY 34 0.96
MD 40 0.88

Newest Health Affairs blog offers states 15 ways to control health costs

While health costs have moderated recently, most experts expect costs to begin rising faster than inflation into the future. As states are powerful health care purchasers, this is a significant strain on budgets. There is also a growing consensus that we are not getting the quality we are paying for. However, a new Health Affairs blog points out that states are also in a powerful position to innovate and find solutions. States have significant regulatory authority over health care including insurance rate setting, provider certification, and convening power, which may be the most salient lever in the currently fragmented system. States can structure reforms to match local circumstances. With flexibility not available to federal regulators, states are leading innovators in cost control and quality improvement. The authors list fifteen options available to states including publishing a scorecard, adopting payment and delivery system reform goals, test alternative payment models, build an All-Payer Database, integrate behavioral health and primary care, adopt evidence-based options, adjust scope of practice regulations, expand telehealth, and decrease unnecessary emergency room use. Many of these ideas have been highlighted elsewhere, including CSG-ERC’s Value Over Volume 2.0 report.