In more federal health news, the nonpartisan Congressional Budget Office released their analysis of the impact of the House’s American Health Care Act yesterday. CBO predicts that 23 million more Americans would lose health coverage in the next decade, 14 million just next year, if the AHCA becomes law. The law would reduce the federal deficit, largely by cutting $834 billion from Medicaid over the next ten years. CBO also predicts that insurance markets would become very unstable for about one in six Americans who live in states that elect the AHCA option to remove community rating and Essential Health Benefit standards now required by the Affordable Care Act. Young, healthy residents of those states would benefit with lower premiums but residents with higher-than-average health costs would see a large increase in premiums if they could even find coverage. According to the CBO, benefits that would likely be cut in those states include maternity, mental health and substance abuse, rehabilitation and habilitation, and pediatric dental care. Residents of those states that need the services removed from Essential Health Benefit standards would face very large increases in out-of-pocket costs or would have to forgo care. Plans in those states may re-institute annual and/or lifetime caps on coverage which would also significantly raise costs for residents with high-cost health needs such as expensive prescriptions, according to the CBO. The AHCA has not been taken up by the Senate; leaders there have stated they intend to start over with a new health reform bill.
President Trump’s FY 2018 budget proposal includes $610 billion in mandatory savings over the next decade by instituting state Medicaid block grants or per capita caps starting in FY 2020. This goes beyond cuts included in the American Health Care Act passed by the House of Representatives three weeks ago. According to the proposal, “The Budget ensures that Medicaid and other programs focus on the most vulnerable Americans that they were intended to serve—the elderly, people with disabilities, children, and pregnant women.” The proposal also includes $250 billion net deficit savings over ten years from repealing and replacing the Affordable Care Act. Other ten-year cuts include a $5.8 billion reduction in CHIP funding and approximately 20% cuts to both the NIH and the CDC. The budget proposes shifting more of the FDA’s budget to industry fees and away from taxpayer funding. The President’s budget estimates $55 billion in federal savings over the decade, including $339 million in Medicaid savings, from nine specific medical liability proposals including caps on damages, safe harbors for providers based on clinical standards, and a three-year statute of limitations. The budget proposes expanding Direct Primary Care in Medicaid, a relatively new capitation model for primary care providers. The proposal includes some expanded funding for emergency preparedness and continues funding to address the opioid epidemic but cuts almost $400 million from the Substance Abuse and Mental Health budget. It’s important to remember that the President’s proposal has to be approved by both houses of Congress and likely will be changed significantly.
Early estimates of health coverage finds that 28.6 million or 9% of Americans were uninsured last year, down 20 million from 2010, according to the CDC’s National Health Interview Survey. At 7.7% uninsured, the Northeast had the lowest rate among four US regions. Among ERC states, Massachusetts still ranks lowest in uninsured rate. All ERC states were below the US average. Vermont was not included in the report due to small numbers. As in past years, states that elected to expand Medicaid and/or develop a state-based insurance exchange under the Affordable Care Act had lower uninsured rates. The survey also found that high deductible health plans are growing nationally from covering 25.3% of Americans under age 65 in 2010 to 39.4% last year.
|Uninsured all ages
|Difference uninsured rates between 2013 and 2016, ages 18 to 64, percentage points|
Representative Stephen Kulik hails from Worthington in Western, MA, and represents 16 rural communities to the north and west of Springfield. Steve went to Newton Junior College, and then attended Northeastern University before finishing his studies at the University of Massachusetts Amherst. Representative Kulik started his public service on his hometown’s Planning Board and then Selectboard. He then served three years as a County Commissioner. Steve was the President of the Massachusetts Selectmen’s Association and the President of the Massachusetts Municipal Association. He has been a member of the Massachusetts House of Representatives for the last 24 years, and is currently the Vice Chair of the House Ways and Means Committee. Steve is the founder and co-chair of the Small Town and Rural Caucus. He is also Chairman of the national organization of state legislators called State Agricultural and Rural Leaders (SARL). Rural and agricultural issues have been a priority for Steve since he began his legislative career.
We asked Steve what he sees as the biggest issue for Massachusetts agriculture. He said the biggest problem with MA agriculture is sustainability, with no growth in rural population and the ‘brain drain’ of young people leaving their small towns after they graduate. The loss of population and the loss of representation at both federal and state levels are a serious concern for education and infrastructure. Forty communities are without broadband access in western MA. Those forty communities account for only 30,000 people out of almost 7 million in the state. Steve said, “It’s hard to get anyone’s attention to help those few towns and their small populations get access to broadband. The private sector won’t help because it is not financially viable, and the towns do not have enough of a voice in Boston to put pressure on the state to provide broadband.”
We then asked the Representative about what he considers to be the biggest issues, outside of agriculture, that the state is facing. He immediately answered, “The cost of health care”. He said it is a $40 billion commitment to provide health care to the residents of the state. Currently 42% of the State budget is health care cost alone. The good news is that 98% of the state’s population has some form of health coverage. The second biggest problem for the state, Steve said, is the loss of revenue over the last few years. The lawmakers admit that they do not fully understand why. They believe that part of the drop in revenues is fewer hours worked and lower wages paid to the employees of the state. The lawmakers also know that purchases at brick and mortar store sales are shifting to internet sales, which has affected sales tax revenue. He also believes that wealthy residents are holding onto investments, because they are waiting to see what happens in Washington in terms of tax policy. Steve’s proudest accomplishment as a Representative has been casting a vote for marriage equality.
Representative Kulik noted with deserved pride that the House was able to complete work on the budget in two days, albeit long days. When we asked how they could manage getting a budget approved in two days he responded with; “Revenue is down, so there is no new spending and plenty of advanced work. We held eight public hearings around the state, each focusing on a different agency. Forty-two percent of health care costs in the budget accounts for much of the discretionary spending. The Governor provides the legislature with a good budget, the lawmakers are involved in decision making with the Governor before the budget even gets submitted to the House. The hearings are held jointly by the Governor, House and Senate.
We asked Steve what he values most about CSG-ERC. He said, “CSG-ERC provides the benefits of a regional forum for agriculture and rural issues. ERC member states and provinces all have similar issues, which sometimes are very different than other regions of the country.” Steve added, “My favorite part of the ERC meetings is learning what other states are working on and how they are solving the problems that Massachusetts might be having.” He learns so much from his peers in other states and considers the attendees to be like family.
Finally, we asked how the state’s remaining dairy farms are faring in this tenuous market. His response was that they are doing okay because the state has a dairy assistance program which provides a tax credit to dairy farmers. The dairy assistance is capped at $4 million in any given year, and is not given when dairy prices are up. Rep. Kulik says that many farms have told him that the assistance has really helped them over the years.
Steve’s last comment was how much he believes in legislative organizations like CSG-ERC and sharing of ideas, solutions and the networking between legislators.
You will be able to meet Rep. Steve Kulik and the other members of the Agriculture and Rural Affairs Policy Committee this summer at the CSG-ERC Annual Meeting, August 13 through 16 in Uncasville, CT. Registration is available online. We hope to see you there.
State Health Compare is an important new resource that will help state policymakers get the information they need. The tool, created by SHADAC, provides state-level estimates across 46 measures of health and health care. Through the site, visitors can create customized reported of state-level health estimates. The tool brings together data from six federal agency sources. Categories include health insurance coverage, cost of care, health behaviors, outcomes, access, utilization, quality of care, public health, and social and economic factors. Metrics include costs of potentially preventable hospitalizations, percent of residents who needed but did not get care due to cost, chronic disease prevalence, weight assessment in schools, and adult cancer screening rates. Data for most measures is available for multiple years, allowing trend analysis. Within most of the 46 measures, the tool allows visitors to dive deeper into the data by subpopulations such as by age, race/ethnicity, and education level. The tool provides a map, state rank and trend display for each metric. The data can be downloaded and exported.
On April 25, 2017, President Trump signed an Executive Order entitled ‘Promoting Agriculture and Rural Prosperity in America’.
The Order establishes an Interagency Task Force on Agriculture and Rural Prosperity, which will be supported and funded by the Department of Agriculture. (To read the full text of the Executive Order, click here)
The Task Force will be comprised of 22 members representing the Chairs and Directors of a wide spectrum of government agencies, and will be chaired by the Sonny Perdue, newly-confirmed Secretary of Agriculture.
The stated purpose of the Task Force will be to identify changes in policy, regulations and law that will promote rural America agriculture. Some areas identified for study are increased educational opportunity in rural communities, regionalization of economic development programs, access to reliable workforce, preservation of family farms, improve science-based food safety regulations and policies, encourage exports of agricultural products, advance renewable energy in the rural landscape and expand access to grazing, timber harvesting, mining and recreation on public lands.
The Task Force will be open to recommendations for legislative, regulatory and policy changes from stakeholders, and will produce a report of their findings within 180 days from the date of signing.
We will be briefing members on news of the progress of the Task Force over the next six months.
Bob Haefner and Tara Sad
CSG/ERC Agriculture & Rural Affairs Policy Advisors
With a few exceptions, health care prices in ERC communities are higher than the US average, according to the Healthy Marketplace Index. The Index is a map-based tool from the Health Care Cost Institute that compares local prices for inpatient, outpatient and physician services across the US for 2012, 2013 and 2014. The researchers found significant price variation between communities, especially in outpatient care. While prices have been rising across the US over those years, all ERC communities’ prices have risen faster than the rest of the nation. Among ERC communities included in the tool, only Baltimore’s prices are lower than the US average for inpatient, outpatient and physician services.
|2014 health cost ratios
relative to US average
|New York – Newark – Jersey City||1.31||1.16||1.1|
|Bridgeport – Stamford – Norwalk||1.27||1.09||1.16|
|New Haven – Milford||1.17||1.03||1.24|
|Hartford – West Hartford – East Hartford||1.15||1.02||1.18|
|Norwich – New London||1.18||1.08||1.04|
|Providence – Warwick||1.04||0.94||0.94|
|Portland – South Portland ME||1.19||0.94||1.1|