ACA repeal, Medicaid, personalized medicine, and bioscience highlight at ERC Annual Meeting

Join CSG-ERC for our 2017 Annual Meeting and Policy Forum August 13 to 16 in Uncasville, CT. Health programming includes a lunch talk on the promise of genomics, the potential of bioscience to improve health and grow state economies, and the potential state impact of federal proposals to replace the Affordable Care Act, significantly change Medicaid funding, and budget cuts. Registration is now open.

Updated: CBO estimates that 22 million more Americans will become uninsured by 2026 under the Senate’s ACA replacement proposal

Thursday morning Senate leaders published their plan to replace the Affordable Care Act and modified it earlier today. The Senate proposal closely follows the bill that passed the House in May. According to today’s Congressional Budget Office’s report, the Senate bill would increase the number of uninsured Americans by 15 million next year and 22 million by 2026, including 15 million losing Medicaid. Increases in the uninsured rate would cross income and age categories, but would fall hardest on low-income and older Americans. The Senate bill would reduce Medicaid funding to states more than the House bill but spreads those cuts out over three years. Under the Senate bill, Medicaid funding to states would drop by $772 billion by 2026. According to the CBO, “With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services.” CBO also estimates that the Senate bill would increase private insurance premiums by 20% on average next year but lower them beginning in 2020 when plans could be less generous. By 2026 premiums would be 20% lower than under current law, but because of less generous plans, consumer out-of-pocket costs would be higher. CBO predicts that some people will “experience substantial increases in what they would spend on health care” depending, in part, on whether states choose to waive Essential Health Benefit standards in current law.

(Update added 6/30/17) A subsequent extended CBO analysis finds that under the Senate bill federal Medicaid spending would decrease even farther in the future. Analysts estimate that under the Senate’s bill, federal spending on Medicaid would decrease by 26% by 2026 and 35% by 2036.

The Kaiser Family Foundation has published a side-by-side comparison of ACA repeal and replacement proposals.

Is Rural America the New Inner City?

On May 26 of this year, the Wall Street Journal published an article entitled “Rural America is the New Inner City”.  We decided to investigate this claim to see if it was, indeed, true.

The Wall Street Journal starts its article with the statement ‘There are twice as many funerals in Rural America as there are Baptisms’. For years, rural America thrived on a combination of mostly light manufacturing, distribution and agriculture.  In many cases across the country, manufacturing and distribution have left the rural areas, and agriculture has in many cases become less labor intensive.

The socio–economic charts have flipped. Rural counties now rank worst among the other categories of urban, sub-urban and small cities in terms of poverty rates, educational level, teenage births and labor force participation rates.  Poverty rates are up 45% in rural America, and income is down 7%.  Comparatively, urban and small city poverty is on the decrease, and incomes up 6%. The WSJ states that opioid use in rural small towns is up and driving the resulting crime rates up as well. As population has declined and businesses have left, real estate values in the commercial sector have plummeted, and many building are left vacant. Employers have said that the loss of employment is not due to a lack of jobs, but a lack of qualified employees. Those business simply moved to suburban areas where the qualified labor exists. A number of rural areas during the ‘80s and ‘90s opened call centers for major corporations. Those call centers have left for overseas locations where labor is cheaper. Advances in telecommunications and technology has enabled this exodus to happen.

Federal and state anti-poverty programs designed to help the urban poor have failed to address the rural poor. Many of those programs helped with public transportation and day care, which is lacking in small towns and rural areas. There has always been a wage gap between non-metro areas and their urban counterparts, but in recent years that gap has grown as manufacturing left the small towns.  The last recession widened the gap as well. While other sectors have recovered from the recession, the rural areas have not.  Consolidation has shut down many rural hospitals in the past decade.  Not only did this cause a loss of jobs and rural income, but it left the residence with much longer drives for health care.  And rural residents are among those most in need of health care, since smoking has not decreased among the rural population as much as it has in the urban centers, and obesity rates have been increasing. Rural America and its small towns do not have the treatment facilities for opioid addiction that our urban and sub-urban counterparts have, and yet the opioid crisis has hit the rural parts of our nation at a disproportionate level.

There has been a lot of federal and state money directed to helping the urban areas of our country, funding efforts to improve education and skills training, medical care, public transportation, jobs and rebuilding the inner cities.  Very little funding has gone to rural America.

In November 2016, many voters in the country’s rural counties cast their ballots for now President Trump in record numbers, thus electing him. He promised to revive our small forgotten towns, reduce regulation, increase trade, curb illegal immigration, and bring jobs back.  Many small town and rural people think Trump cared about their plight, and felt that other politicians have not for a number of years.

Let’s look at some USDA data.  While the population drain from rural to urban areas in 2015 slowed to no loss of population from rural counties, the population shift for the last half of the prior century was dramatic.

Percent of US Population


Rural Counties Urban Counties Suburban Counties
1950 44% 33% 23%
1999 18% 25% 57%


As of 2014 only 14% of the population is rural, but those rural counties amount to 72% of the land mass of the country.  Many farmers, departments of agriculture, and conservationist have pointed out that the 14% of our population produces 90% of our food on that 72% of the land.  Many counties are continuing to lose population, and what population remains is getting poorer.  These rural counties have lost a total of 650,000 people over the last four years.  But there is a flip side – other rural counties gained a total of 500,000 people, decreased poverty rates and increased employment levels.

From 2000 to 2015 total rural population grew at a rate of 4.5%. During that same period, the rural Hispanic population grew at a rate of 45%. The USDA commission on Rural Affairs states that currently rural employment is lagging urban employment.  The largest population losses are in the most remote areas. They also report that much of the loss of employers are due to the closing of large industrial plants, other manufacturing and distribution, and farms that have become more efficient with technology. Service producers and retailers are the bright spot, albeit paying lower wages.

One more set of statistics paints a rosier picture of rural America.  It is safer to live in Small Town USA. Urban violent crime per 100,000 is 74% higher than rural towns, and even the suburbs have a violent crime rate 37% higher than their rural counterparts. Gun crimes are far higher in both urban and suburban locals than in rural counties. And 95% of rural household own a car, while only 13% of inner city households do (although the presence of rapid transit in urban areas reduces the need for automobile ownership).

Now that we have begun to dig through data and ireports, we have found that there is a vast amount of information available on the subject – enough to warrant a second blog on the issue of urban vs. rural, which we will be bringing you soon.

Meet the Legislator – MA Senator Anne Gobi

Senator Anne Gobi lives in Spencer, Massachusetts, the town where she was born and raised. After graduating from Worcester State College, Anne studied law at Massachusetts School of Law at night while teaching high school during the day.  After passing the bar, she went into private practice.

A member of the Spencer Democratic Town Committee since 1998, Anne was asked to run for an open seat in 2001.  We asked her if she was anxious about the campaign.  ‘I had never run for anything before this.  The representative in the district before me was a Republican.  Raising money was the hardest part.  I had a primary in my first election, and I had to raise over $50,000 for the campaign, which was hard.  But I won.’  She was a member of the Massachusetts House of Representatives for 14 years, serving on multiple committees including the Joint Committee on Environment, Natural Resources and Agriculture, of which she was co-Chair.

We asked her why she chose go serve on the Agriculture Committee.  ‘In Massachusetts, we have a wish list for committee assignments.  When I was first elected, I was assigned to committees.  But since I grew up active in 4-H and live in a rural district, I wanted to serve on the Agriculture Committee, which I did.  It took me a while to be named chair, but I was, and eventually served two terms as Chair.’  Anne was elected as State Senator in 2014, and she is currently in her second term as Chair of the Senate Ag Committee.

We asked if she likes being a Senator.  ‘I like it, even though there is a lot of work.  Over 300 bills come to my committee during the biennium, and I make sure that the committee works hard on each one.

When we asked what the biggest issue was facing agriculture in Massachusetts today, Anne did not hesitate.  ‘Farm viability.  Massachusetts has 7,000 farms, but most of them are very small.  Last year’s drought affected them badly.  We have to find a way to make farming sustainable for our farmers.’  Another problem with agriculture in the state is the number of outdated laws, particularly the agricultural preservation statutes. The way they were written when people went into them thirty years ago is not the way things are now.  It is a challenge updating laws so that farms can have viability and diversify on their farm so they can survive.  Young farmers need the help most.

Ann said that Massachusetts is losing an alarming number of dairy farms. ‘We’re down to about 160, roughly.  There were thousands at one time.  Within the last ten years we have lost another 25’

She is optimistic with some new trends in agriculture.  ‘Farm breweries are cropping up.  There is a Barre dairy farm that is milking cows and selling beer as well.  One woman who works there said ‘15 cents for a pint of milk, $7 for a pint of beer.’

According to Anne, the biggest non-agriculture issue that the Massachusetts Senate faced this year is the fact that revenues are not coming in at the pace they should be.  Uncertainty on the federal level and the effect that will have is a huge worry.  Health care is almost 51% of the budget.  The state is facing a $870 million deficit.  Currently the state has no tax on online sales.  There should be a way to capture this revenue that has been lost due to the closing of brick and mortar stores in favor of online sales.  Also Massachusetts is home to a large number of financial institutions and service industries that pay no taxes.

Senator Gobi said the thing she likes most about being in the legislature is that it is never boring.  There is a different issue every day.  ‘You never know when the phone rings or when you open an email what is going to be there.’  She likes to keep active, and the legislature helps to provide change and challenge.  What she dislikes most is her long commute to the statehouse, which takes a lot of valuable time out of day.

e says she has enjoyed working and being invited to CSG-ERC meetings and seminars.  She especially likes that she is able to go online and get information on what is happening in other states and in Washington.  This resource is tremendously helpful to her and her staff.

Come and meet Senator Anne Gobi and other dedicated legislators interested in Agricultural and Rural Affairs policy this summer at the 2017 CSG-ERC Annual Meeting in Uncasville, Connecticut (‘Mohegan Sun’) from August 13 through 16.

Report estimates AHCA cuts $373.6 billion in Medicaid funds to ERC region

CSG-ERC region states would lose $127.1 billion in Medicaid funding from 2019 to 2028 under the American Health Care Act passed by the House last month, according to a new report from the Urban Institute and the Robert Wood Johnson Foundation. Most states are not in a position to fill the Medicaid funding gap that would be created by the AHCA and the authors note that provider rate and benefit cuts are unlikely to generate much savings. States will have to decide whether to fill some or all of the gap with state funds, or cut eligibility to keep state funding level. If all ERC states choose the latter, three million residents of the region would lose coverage. The authors point out that their estimates are very sensitive to changes in Medicaid spending growth and per capita cap growth rates.

Federal Medicaid funding loss, 2019 – 2028 People losing Medicaid coverage to keep state funding level, 2022
CT $5.9 billion 179,600
DE $2.2 billion 47,200
ME $600 million 15,100
MD $11.7 billion 312,700
MA $10.3 billion 355,400
NH $2.2 billion 74,000
NJ $27.5 billion 587,100
NY $46.3 billion 738,700
PA $15.8 billion 612,700
RI $2.9 billion 63,800
VT $1.7 billion 42,500
ERC total $127.1 billion 3,028,800
US total $373.6 billion 14.8 million

ERC states high health care spenders per capita but very good news on Medicaid trend

New data from CMS actuaries finds that per capita health care spending in all CSG-ERC states was above the US average in 2014. The CSG-ERC region made up eight of the top ten most costly states. Massachusetts was the most costly in the region, behind only Alaska nationally. While all CSG-ERC states average annual rate of growth from 1991 to 2014 was at or above the US average, five were average or very close. Vermont was tied with Alaska at 6.6% for the fastest rate of growth. In good news, per capita Medicaid spending dropped in seven ERC states from 2010 to 2014. Six of the ten states with biggest drop in Medicaid rates were in the ERC region. Connecticut led the nation with a 5.7% drop in per capita Medicaid spending. Nationally, Medicaid spending per person didn’t rise at all while Medicare rose by 1.2% and private health insurance was up 3.3%.

Per capita health care spending total


avg annual % growth,

total 1991-2014



Avg annual % change


CT $9,859 4.9% $8,058 -5.7%
DE 10,254 5.7 6,921 1.1
ME 9,531 5.9 7,504 -1.1
MD 8,602 5.0 7,677 -1.9
MA 10,559 5.2 8,922 -5.6
NH 9,589 6.1 9,129 -2.3
NJ 8,859 4.9 8,049 -5.4
NY 9,778 5.0 9,803 -1.5
PA 9,258 5.0 9,407 3.2
RI 9,551 5.3 10,934 0.2
VT 10,190 6.6 7,917 2.4
US average 8,045 4.9 6,815 0.0

U.S. to Withdraw from Paris Agreement, but Many CSG/ERC States Committed to Carbon Reductions

President Trump today announced that the United States will exit the historic Paris Agreement, whose 195 signatories agreed to reduce their greenhouse-gas emissions in an effort to combat climate change. Only two other nations in the world are not party to the accord: Syria and Nicaragua.

In a memo released by the White House, Trump called the pact “a bad deal for Americans.”

The Paris Agreement seeks to limit the rise in Earth’s temperature to 2 degrees C (3.6 degrees F) above pre-industrial levels. Under the Obama administration, the U.S. had committed to lowering nationwide carbon emissions 26 to 28 percent below 2005 levels by 2025.

Several northeastern states have policies in place that would meet or exceed those targets, and have been implementing programs to reach their goals (see chart below).  

In a letter last month, governors from 12 states, including five in the CSG/ERC region, urged the President to remain in the agreement, noting their successful track records in lowering carbon emissions while growing their economies and producing jobs. “Given the progress our states have made in reducing greenhouse-gas emissions, we are convinced that the United States’ goal of 26-28 percent below 2005 levels is readily achievable,” they wrote.

The Paris accord lays out a four-year exit process starting in November 2016, when the agreement took effect.

During the upcoming 2017 CSG/ERC Annual Meeting in Uncasville, Connecticut on August 13-16, CSG/ERC’s Energy & Environment Program will bring together policymakers from the northeastern U.S. and eastern Canada to discuss the challenges, and opportunities, for state clean-energy and carbon policies in the absence of the U.S.’s participation in global efforts to address climate change.  


Carbon and Renewable Energy Policies in the Eastern Regional Conference

State/Province Carbon-Trading Program Statewide Carbon-Reduction Goals & Participation in International Efforts Renewable Portfolio Standard
Connecticut RGGI[i] 10% below 1990 levels by 2020 (goal reached in 2012); 80% below 2001 levels by 2050.
Signatory of the “Under 2 MOU.”[ii]
Member of the Zero-Emission Vehicle (ZEV) Alliance.[iii]
27% by 2020
Delaware RGGI 30% below 2008 levels by 2030 (target recommended by a cabinet committee). 25% by 2026
Extra credit for solar or customer-sited renewables.
Maine RGGI 10% below 1990 levels by 2020; 75% -80% below 2003 levels in the “long term.” 40% by 2017.
Maryland RGGI 25% below 2006 levels by 2020; 40% below 2006 levels by 2030; 80% below 2006 levels by 2050.
Member of the Zero-Emission Vehicle (ZEV) Alliance.
25% by 2020.
Massachusetts RGGI 25% below 1990 levels by 2020; 80% by 2050.
Signatory of the “Under 2 MOU.”
Member of the Zero-Emission Vehicle (ZEV) Alliance.
15% by 2020 (new resources) and additional 1% per year thereafter; 6.03% by 2017 (existing resources). Mandated in-state solar PV target of 1600 MW by 2020. Legislation enacted in 2016 requires distribution companies to enter into cost-effective long-term contracts for 1,600 MW of offshore wind power by 2027 and 9,450,000 megawatt-hours of hydropower or other renewables by 2022.  
New Hampshire RGGI 20% below 1990 levels by 2025; 80% by 2050. Signatory of the “Under 2 MOU.” 24.8% by 2025.
New Jersey None 20% below 1990 levels by 2020; 80% below 2006 levels by 2050. 20.38% by 2020, plus 4.1% solar by 2027. Legislation enacted in 2010 requires that at least 1,100 MW of Class I renewable power come from offshore wind.
New York RGGI 40% below 1990 levels by 2030 from the energy sector; 80% below 1990 levels economy-wide by 2050.  
Signatory of the “Under 2 MOU.”
Member of the Zero-Emission Vehicle (ZEV) Alliance.
50% by 2030.
Pennsylvania None No clear targets. 18% by 2021
Puerto Rico None No clear targets. 20% by 2035
Rhode Island RGGI 10% below 1990 levels by 2020; 45% by 2035; and 80% by 2050.
Signatory of “Under 2 MOU.”
Member of the Zero-Emission Vehicle (ZEV) Alliance.
38.5% by 2035
U.S. Virgin Islands None No clear targets. 20% by 2021.
Vermont RGGI 50% below 1990 levels by 2028; 75% below 1990 levels by 2050.
Signatory of the “Under 2 MOU.”
Member of the Zero-Emission Vehicle (ZEV) Alliance.
20% by 2025; 75% by 2032; 90% by 2050.
New Brunswick None 10% below 1990 levels by 2020; 75%-85% below 2001 levels by 2050. 40% by 2020.
Nova Scotia None 10% below 1990 levels by 2020; 80% from “current levels” by 2050. 40% by 2020.
Ontario Cap-and-trade program currently being developed.[iv]  Plans to link to Québec and California programs. Manitoba is expected to join as well. 15% below 1990 levels by 2020; 37% below 1990 levels by 2030; 80% by 2050.

Signatory of the “Under 2 MOU.”

2009 Green Energy Act created feed-in-tariffs for a number of energy sources. Goal for 20,000 MW of renewable energy by 2025, representing half of Ontario’s installed capacity.
Prince Edward Island None 75%-85% below 2001 levels by 2050. 15% renewable energy per year, beginning in 2010. Requirement eliminated in 2016. (25% of PEI’s electricity currently comes from wind energy.)
Québec Cap-and-trade program[v] linked to California and in the future, Ontario and potentially, Manitoba. Covers 85% of province-wide carbon emissions. 37.5% below 1990 levels by 2030.
Signatory of the “Under 2 MOU.”
Member of the Zero-Emission Vehicle (ZEV) Alliance.
Increase renewable energy production 25% by 2030. (99.5% of Québec’s electricity comes from hydropower, wind and residual biomass.)



[i] RGGI applies to fossil-fuel fired electric power generators with a capacity of 25 megawatts or greater.

[ii] Signatories of the “Under 2 MOU” agree to either reduce greenhouse gas emissions 85% to 90% below 1990 levels by 2050 or achieve a per-capita annual emissions target of less than 2 metric tons by 2050. As of April 2017, 170 governments had signed the agreement, representing 37% of the global economy.

[iii] The Zero-Emission Vehicle (ZEV) Alliance is an effort among 13 North American and European governments to make all new passenger vehicles sold in their jurisdictions emission free by 2050.

[iv] According to proposed Bill 172, “The Climate Change Mitigation and Low-Carbon Economy Act of 2016,” the program would apply fossil-fuel distributors, industrial and large commercial operators and institutions that emit at least 25,000 metric tons of equivalent CO2 per year.

[v] Québec’s cap-and-trade program applies to businesses that emit at least 25,000 metric tons equivalent of CO2 per year. This includes the industrial and electricity sectors and fossil-fuel distributors.

CMS seeking public comment on new informed consent payment proposal

There is an exciting new opportunity to support patient-centered care and make a meaningful impact on the quality of care in hospitals across the US. CMS is seeking public comment on a proposed Medicare rule (regulation) for how hospitals are paid that includes a new measure assessing the quality of hospital informed consent documents given to patients before elective procedures. The current state of hospital informed consent documents is poor. If adopted, the 4,700 US hospitals that treat Medicaid members would be paid, in part, based on the quality of their informed consent documents. The measure could also be included in public quality comparisons such as Hospital Compare, allowing patients to use this measure in choosing between hospitals for their care. Comments are due by 5:00 pm EDT on June 13th. Click here for more info, links to the proposed rule and the measure specifics, a customizable template for comments, and directions on how to submit comments.

CMS has not made a decision whether to support the informed consent document measure for implementation. CMS is seeking feedback to help with their decision.