State policymakers urge Congress to preserve successful state-federal Medicaid partnership

Yesterday, CSG-ERC sent a letter calling on Congressional leaders to protect and support the 50-year, successful state-federal Medicaid partnership. Signed by ERC Co-Chairs Sen. Terry Gerratana and Rep. Kevin Ryan (CT) the letter notes that state legislators represent the same constituents as members of Congress. As the letter points out, “For over fifty years, Medicaid has been a beacon of effective state and federal collaboration. The program delivers critical preventive and acute care services to one in five residents of our region. Medicaid serves the needs of the most fragile Americans, provides financial security for families, and is a cornerstone of state health systems and economies.” The letter follows an ERC Resolution passed last December also supporting the Medicaid state-federal partnership.

Meet Delaware Senator Gary Simpson

Senator Gary F. Simpson, representing the 18th Senate District of Delaware, has been in the legislature since 1998. The Minority Leader in the Senate, Gary also sits on the Agriculture, Executive, Rules & Ethics committees, and is a member of the Legislative Council. He retired from twenty years with the University of Delaware in 2011, and before that served as the general manager of the Delaware State Fair. He is also the Co-Chair of the CSG-ERC Agriculture & Rural Affairs Policy Committee.

We asked Sen. Simpson what prompted him to run for the Senate that first time. “I was working for the University of Delaware at the time, and he had some free time. I had experience working with the legislature in my position, and so when I was asked to run, I thought it would be a great new challenge for me. I had had leadership roles in other avenues of life, and felt I could bring that experience to the office.”

Although Gary had never run for office, never been involved in politics in any way, and never even gone to a county meeting, he had lived and worked in every area in the senate district, and he won the election in a seat that had been held by the other party for a quarter century. And he has won every election since. “The almost twenty years has gone by so quickly,” he adds.

Knowing Senator Simpson’s love of agriculture, we asked him what is the biggest Agricultural issue facing Delaware today? “Nutrient management is our main problem,’ he said. ‘Delaware is a coastal state. We have many inland waterways and bays. We are constantly fighting to control nutrient management, and to educate the people who think that agriculture is the sole blame for the pollution.”

Another issue of critical importance is the threat of avian influenza. Poultry is a huge industry in Delaware, as are the associate industries of soybeans and corn that feed the industry. An AI outbreak could be devastating for the state. ”We had an outbreak several years ago,” Gary said, “and we developed a strong protocol to manage Avian Influenza, but we have to always be vigilant for another outbreak. Delaware is a flyway for geese and other migratory birds, so the threat is there.”

Urban sprawl continues to eat up farmland due to the lure of coastal living and low property taxes. “We have an active farmland preservation program that the state has funded for the last twenty years,” Simpson notes. “Whether it will continue to be funded in this current budget cycle has yet to be seen.”

Changes to trade agreements under the new administration might negatively impact the robust exports Delaware is enjoying with Russia and China. ‘A lot of countries are buying chicken products, and we want to see that trade continue,’ he says.

We asked what he likes the most, and the least, about being a Senator. “I like solving problems,” he says. “Problem solving has been my forte both in public and private life.   Suggesting paths forward, finding solutions – that’s what I enjoy most.” He added, “There was a United States Senator, Bill Roth, who I use as a role model. Whenever anyone called his office from anywhere in the state, Senator Roth’s staff got back to that person in a quick manner to help solve the problem. I make it a point to try to do the same with my constituents.”

What he dislikes is politics. He sees legislators on both sides of the aisle being so tied to the political party they can’t see the other side. Votes are being taken straight down party lines.   “We’ve dirtied the word compromise”, he notes. “You get more done if you compromise.” This is why he likes the agriculture committee, because members from both sides of the aisle work together for a common goal of advancing agriculture in Delaware.

We asked how CSG-ERC helps him in is work. “I think we each have our own strengths in agriculture, whether it be dairy in PA, vegetables in NJ or poultry in DE. We can each benefit by hearing each other’s problems, and by seeing how each has have solved them. The sessions during our annual meeting where ag legislators compare notes about issues affecting their states is always incredibly helpful and informative.”

At the end of our interview, we asked what advice he might have that would help first time legislators. “Don’t take yourself so seriously. That is probably the biggest downfall of a lot of political folks.   They think the world will not continue without them. They are wrong. We can all be replaced.   Think of your term in office as an opportunity to serve and be involved, but know that other people can do it better.”

We doubt that that is true of Sen. Gary Simpson, who is one of the agricultural leaders who will be attending the CSG-ERC Annual Meeting in Uncasville, CT from August 13 through 16. We hope to see you all there.


Bob Haefner and Tara Sad

CSG/ERC Agriculture & Rural Affairs Policy Advisors

Vermont rates highest among all states in public health emergency preparation

This year the US earned 6.8 points out of 10 possible in the latest assessment of preparedness for community health emergencies, an increase of 1.5% over last year. The National Health Security Preparedness Index has measured states’ ability to respond to health security threats such as a Zika outbreak or a natural disaster for the last four years. The Index includes metrics such as vaccination rates, hazard plans for public schools, the number of paramedics and hospitals. The US overall performed best (8.2 points) for Incident and Information Management, and worst (5.3 points) for Healthcare Delivery. Vermont scored best among all states with 7.8 points. All ERC states equaled or exceeded the US average. The report includes detailed information on each state’s performance and challenges. The report concludes with areas that need work to ensure public safety in public health emergencies.

CT 7.3
DE 7.2
ME 7.4
MD 7.5
MA 7.3
NH 7.3
NJ 6.8
NY 7.4
PA 7.0
RI 7.5
VT 7.8
US average 6.8

Milbank publishes study of state health policy capacity resources and needs

State policymakers are responding to an unprecedented set of very complex policy changes that can shift quickly including Medicaid expansion and options, insurance standards and exchanges, public health changes and more. These policies represent a significant piece of state budgets, must engage many stakeholders, and are central to the health and quality of state residents. Policymakers must translate these opportunities and challenges in ways that fit the unique features of their state. Many of these policies require state implementation and operation; all of them require state attention. A new study for the Milbank Memorial Fund assesses how state policymakers have made decisions and implemented policies in the new environment, what resources they relied on, and what is still needed. There is a lot of important information in the report including the central role of trust among public officials, the importance of staff policy capacity, federal resources (but not necessarily federal technical assistance), and sharing lessons learned among states. States also outlined policy capacity needs including policy skill building for state staff, implementation skill capacity, and data access, analysis and management. The authors conclude with a capacity checklist of what policymakers need to succeed.


A subsequent brief dives deeper into the experience of state policymakers in creating state-based insurance exchanges.

A First Look at President Trump’s USDA Budget for 2018

Any budget proposal is, by its nature, partisan.   However, we will present the facts as we know them, in a non-partisan manner, and let you decide if you agree or disagree with the budget proposal. We must keep in mind that the President’s budget is merely a proposal. Once the executive branch presents the budget to the US House of Representatives, it is under their control and is no longer the President’s budget. Of course, any President has some influence over what the Congress does with the proposed budget, especially if they are of the same party affiliation. Any proposed budget reflects the priorities of the submitter of that budget. However, we can be assured that, as the budget wends its way through legislative channels, it will take on the priorities of the legislative branch.

That allocation of limited revenue to programs is how we prioritize what is important to a given administration and what makes budgeting a partisan issue. Democrats have different priorities than Republicans, or Libertarians, or even Independents. As the Vice Chair of the NH House Finance Committee often says, “For every one of the thousands of lines in the budget, there is an advocate who says, ‘Cut any line you want except this one’. If you listen to every advocate, you would never cut a penny from the budget.”

Now let’s look at the Trump proposed budget and how it affects the USDA. The proposed budget recommends a 21% cut to total USDA discretionary line items. It does not propose any cuts to mandatory portions of the USDA budget. So the Nutrition Title has not been touched, which includes programs such as the Supplemental Nutritional Assistance Program (SNAP), school lunches and children’s nutrition program. The President’s full proposal is not scheduled to be released until May. Of course, Congress alone can make changes to mandatory spending, since these changes require amending law to affect that part of the budget. This budget proposal really only affects programs that benefit our farmers, and it is the fact that it affects our farmers that makes it critical for   to the Northeast Agriculture Legislators. It is important to note here that this budget proposal came from the White House Budget Director Mulvaney and was not reviewed by the USDA since there was not a confirmation of the nominee at the time.   What impact Secretary Perdue’s involvement in the proposal’s outcome would have had is unknown..

The USDA budget is $155 billion, of which $133 billion (85%) is mandatory spending for nutrition programs and its administration. That leaves $22.6 billion, which is discretionary and allocated for our farm programs. That number had been higher in past years, but between recent sequestrations and cuts from the last administration, it is down to $22.6 billion. The Trump proposal cuts another $4.7 Billion, bringing the discretionary total to $17.9 billion (a 21% cut). The only nutrition program in the $22.6 billion (before the cuts) is WIC. The proposal cuts $150 million from WIC, about half of the previous administration cut of $273 million, based on reduced enrollment due to higher employment numbers. The USDA discretionary spending is one-tenth of 1% of the total federal budget, and yet the USDA has 4,500 offices across the country and territories, and has nearly 100,000 employees spread over 30 different agencies.

So what has been cut in this proposal?  Let’s take a look at what the proposal for the USDA discretionary budget really does based on the information as we have it. ‘Discretionary Spending’ includes Food Safety (meat processing), Rural Development, Conservation, Research Grants, and International Food grants. Cuts do not affect the various insurance programs, such as crop insurance.

International Food Aid  – $200 million

Water and Waste Disposal loans and grants  – $500 million

Rural Business Cooperative Service  – $95 million (duplicative)

Funding for National Forest Service  – No new land purchases

Reduced Staffing  –  All levels

WIC  –  $150 million

In addition, there will be cuts to some statistical services and other areas not yet identified.

While this discussion may be premature considering the many unknowns, we thought it important that we share the information at hand. We will continue to give updates as new data becomes available. In May, the full budget will be rolled out, and our new Secretary of Agriculture and Congress will have their go at the budget. It will be debated by the two parties of the House of Representatives.

In August at the CSG-ERC Annual Conference in Uncasville (Aug. 13-16), and in conference calls starting next month, we will also work as a region to develop a regional position on the Farm Bill, currently in negotiations. This will, of course, affect the following budget cycle. As individual states we are relatively insignificant, but as an eleven-state region, we have 87 members in the US House of Representatives – or 20% of the total votes. So we are not insignificant when we work together.


Doctor compensation continues to grow, ERC region lower than rest of US, Canada higher

US physicians average $294 thousand in compensation this year, up from $206K in 2011 according to Medscape’s 2017 Physician Compensation Report. However of nine US regions, physician payment in the Northeast is 6th and Mid-Atlantic states rank lowest. The only ERC state among the top ten is New Hampshire where physicians average $337K in annual compensation. Four ERC states – Maryland, Rhode Island, Delaware and New York – are among the lowest ten states. Canadian physicians are the only nationality paid more than Americans, on average. Specialists make 46% more than primary care physicians, and their compensation is growing faster as well. Among specialties, orthopedists make the most while pediatricians the least. Three quarters of physicians receive employer-subsidized health benefits and 61% receive dental insurance benefits. While still only a third of physicians (36%) participate in Accountable Care Organizations, that number is up from 3% five years ago. About half (52%) of primary care physicians have experienced an influx of new patients since implementation of the Affordable Care Act, only 38% of specialists have experienced that trend. Thankfully, 69% of physicians expect to continue to take new and current Medicare and Medicaid patients; 6% won’t take new patients and 2% won’t see their current patients. Three quarters discuss the costs of treatment with patients, either regularly or occasionally. More than half spend over 10 hours/week on administration and paperwork; that number is rising. In very good news, the vast majority in all specialties would choose medicine again as a career.