State legislators may offer hope for health care cost reform
Politics at the state level are much less divisive, offering a key opportunity to make inroads.
Policymakers seeking to rein in health care costs and improve outcomes and access to care for individuals, take note: Reforms could be closer at hand at the state rather than federal level.
That’s one of the major conclusions of a three-year dialogue with state legislators nationwide conducted by Milbank Memorial Fund, an endowed national foundation that supports research of issues related to population health and health policy.
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Researchers queried state legislators specifically on their health policy priorities. Since “cost” emerged as the leading priority, they probed their thinking about health care costs–for instance, what did cost mean to them? The cost of care to individuals, payers, insurers or government?
The report, “Bipartisan Approaches to Tackling Health Care Costs at the State Level,” tells us that there tend to be more consensus on top priorities than might have been expected in an era of divisive partisan politics. In part, they found, that’s because there are more moderate Republicans lurking in statehouses than they had realized. And these moderates, Milbank says, hold the key to identifying priorities that can be solved at the state level.
The following are the study’s five major findings:
1. In many states, three parties exist, not just two.
About a third of state legislators “fit better in a third group comprising moderates from each party.” The far-right Republicans were more likely to rank reducing the role of government as most important, whereas traditional Democrats said this was their lowest priority. Their top goal was to increase access to care for more people.
Moderate Republicans in this third group say that reducing the role of government is a low priority. Top priority? “Improve overall health.” The report says: “A coalition of such moderates is bridging divides on health care costs even in states with intense partisan splits, like Michigan.”
2. The health care cost priorities cited by legislators are not partisan.
“This finding of a nonfinding is at first glance frustrating but might actually be good news. It suggests that people’s understanding of what they mean by ‘health care costs’ is not hard-wired or ideological.” Thus the possibility exists to create a definition for cost that is acceptable to a majority.
3. All legislators, regardless of party affiliation, “placed a high priority on pharmaceutical costs.”
This could pave the way for a state-level lobbying of changes among the Big Pharma cohort, an effort that generally falls short of effectiveness in Congress. It may be the lowest-hanging fruit of all–but the picking will not be easy.
4. Solving health care cost challenges remains a partisan divide.
“Legislators in the predominantly Republican group tended toward solutions focused on the impact of high costs on individuals, whereas Democrats and moderates from each party tended to support solutions trying to understand and mitigate the systemic drivers for those high costs.” Again, a coalition of mainstream Democrats and moderates could drive reform.
5. Pockets of expertise represent the sweet spot for cost reform.
The study defines a pocket of expertise as “a small number of people who have spent considerable time thinking about health care costs and have developed channels of information sharing with each other. These policymakers almost universally thought about solving health care costs in systemic terms and were able to move the conversation in their states in this direction.”
In states where such pockets exist, action is much more likely to occur as a reform coalition involving the moderates is forged. “People in these pockets of expertise are framing proposals about health care costs to appeal to legislators focused on both individual and systemic drivers of cost by emphasizing both affordability and transparency.”
Affecting nationwide change at the state level presents its own challenges. States ripe for reform coalition formation need to be identified. Those coalitions need to agree on an agenda. Coalition gains must occur in enough states to make a national statement.
But that kind of strategy could bring about positive outcomes more quickly than a stalemated Congress, one that has not been able to agree on any sort of forward movement on cost, access, and outcomes since the Obama era.
To give a bit of perspective to the scope and timing of the study: The researchers gathered data from all states, and followed up with interviews of legislators in Colorado, Vermont, Michigan and South Carolina to collect anecdotal information. And, it was concluded in 2019–prior to the COVID outbreak, so legislators’ current health care cost priorities could have changed in the last year. But if anything, the research team believes cost reduction may now be an even greater priority than it was prior to COVID.
“It is hard to know exactly how perspectives have changed as a result” of the report’s timing, they say. “But it’s likely that the resulting health and economic crises have intensified pressure on state leaders to come together and tackle health care costs.”
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