Health Chairs Project Survey of State Health Priorities for 2003

INTRODUCTION

In a recent survey of legislative priorities, 69 chairs of state health committees, representing 44 states, named their three top priorities for the 2003 session. As in 2002, cost and financing dominated the agenda in 38 states. Access and workforce issues are on the agenda in more than 40% of states, while 13 states indicated that medical malpractice would be high on the agenda.

ISSUE

Chairs

States

#

%

#

%

Health Care Costs and Financing

Medicaid 35 51 27 61

Prescription Drugs 20 29 16 36

General 14 20 14 42

TOTAL 50 72 38 86

Access to Health Care/Insurance 23 35 17 39

Health Care Workforce and Providers 20 29 19 43

Medical Malpractice 15 22 13 30

Aging, Long-Term Care, and Nursing Homes 15 22 12 27

Mental Health and Substance Abuse 12 17 12 27

Conventional Public Health and Disease Prevention/Management 12 17 12 23

Bioterrorism and Emergency Public Health Responses 5 7 5 11

Administrative Reorganization 5 7 5 11

Oral Health 3 4 3 7

Stem Cell Research 3 4 3 7

METHODOLOGY

The Health Chairs survey was conducted by the Health Chairs Project, a collaboration between the National Conference of State Legislatures (NCSL) and the Schneider Institute for Health Policy at Brandeis University.

This year’s survey was in a simpler format than previous years. Chairs were asked two open-ended questions: to identify the top three health priorities facing their committee during the 2003 legislative session, and to name the health issues of greatest personal importance. These questions were part of a request for legislators’ biographies for NCSL’s annually updated directory of health chairs. The survey was sent to the chairs of every full standing health care authorization committee in the 50 states and D.C. (approximately 103), and to chairs of subcommittees of health committees, health-related committees, and health finance/appropriations committees. Of the 69 legislators who responded to the survey, 50 are currently chairs of full standing health committees, 9 are chairs of health-related committees, 9 are chairs of health finance/appropriations committees, and 1 is a chair of a subcommittee of a full standing health committee.

Health committee chairs (including chairs of standing health care authorization and finance committees as well as chairs of health subcommittees and health-related committees) play a critical role in setting state health policy agendas and are integral figures in the establishment of health care initiatives and legislation. By introducing legislation and setting the agenda for state-level debate, the 160-plus health-related committees in state legislatures play a critical role in identifying emerging and urgent health policy issues. In recent years, state action on priorities such as pharmaceutical benefits for the elderly and medical malpractice has set the stage for federal deliberation on these issues.

Respondents Reflect the National Political Make-up

Fifty-two percent of respondents are Republicans (36) and 48 percent are Democrats (33). This closely resembles the national political makeup, where 50 percent of state legislators are Republican and 49 percent are Democrats. Forty-six percent of respondents are Senators (32), and 54 percent of respondents are Representatives/Assemblymembers (37), reflecting the distribution of committee chairs across upper and lower legislative bodies.

FINDINGS AND ANALYSIS

Health Care Costs and Financing

For yet another year, health care costs and budget shortfalls are expected to drive state agendas. Seventy-two percent (50) of legislators identified health care costs and financing-related issues as their committee’s primary focus, making it the most frequently cited issue area of 2003. This number was only slightly lower than last year’s response of 75 percent.

Due to the variety of responses that fit under this category, we divided the responses into three sub-categories: Medicaid financing, prescription drug financing, and general financing. Fifty-one percent of legislators (35) indicated that Medicaid financing would be a top priority in their committees in 2003, making it the most frequently cited priority among chairs. This comes as no surprise given that Medicaid is the second largest item in most state budgets, after education. Medicaid concerns often mingled financing and access and were expressed in a variety of ways, including “slowing Medicaid cuts” (Representative Charlie Brown-IN); “Medicaid curtailments and impact” (Representative Thomas Kane-ME); and “protecting Medicaid eligibility” (Sen. Ben Robinson-OK). A few legislators mentioned specific actions their committees might take to mitigate the effects of proposed budget cuts, such as pursuing “cross-over claims” for clients who were also eligible for Medicare (Representative Dave Heaton-IA) and “maximizing the Medicaid match” (Representative Jay Bradford-AR). This category also includes responses pertaining to the State Children’s Health Insurance Program (SCHIP). For instance, Virginia Delegate Phillip Hamilton cited “Children’s Health Insurance revisions” as a priority.

Twenty-nine percent (20) of legislators listed prescription drug costs as a priority. These responses ranged from “budget cuts impact on prescription drugs (Senator Richard Moore-MA) to more specific management tools to control costs, such as “preferred drug lists” (Delegate Don Perdue-WV). Finally, 20 percent (14) of legislators stated that health care costs or budgetary concerns, in general, were a priority. Hawaii Senator Rosalyn Baker listed “financing for health care services” as a priority, while New Hampshire Representative Peter Batula raised “problems of budget constraints” as a priority.

Some surveys simply cited “prescription drugs” or “Medicaid,” without elaboration. We have categorized all responses related to prescription drugs and Medicaid under the “health care costs and financing” heading, because this was the theme of the more expansive responses. As described above, some could also have been classified as access. We did not include these under the separately defined category “access to health care and insurance” (see below) to avoid double counts. Thirty percent of legislators responding with a phrase related to “prescription drugs” stressed access more than cost. For example, Michigan Representative Stephen Ehardt’s statement, “No senior should have to choose between medication and food,” illustrates the fine line that exists between access and cost when discussing prescription drugs. Responses dealing with Medicaid were similarly difficult to assign to a single category. Most legislators simply stated, “Medicaid reform,” while one remarked, “expanding use of Medicaid,” both of which could suggest financing and/or access issues.

The prominent focus on health care costs was expected. As they enter their third straight year of budget shortfalls, states have had to close a cumulative $200 billion budget gap. The situation is not much brighter for fiscal year 2004. As states craft their budgets for the next fiscal year, estimates show that 41 face a cumulative budget gap of $78.4 billion. While the outlook is dismal in the short-run, there may be hope for the future. The U.S. House and Senate recently reached a compromise on an economic stimulus package that promises $20 billion in state aid, $10 billion of which is earmarked for Medicaid. It will be interesting to see how this new revenue stream affects health chair priorities in the coming years.

Health Care Access and Availability

Issues related to health care access for people not covered under Medicaid and SCHIP were identified as a top committee priority by 35 percent of chairs (23). This issue ranked second only to health care costs as the most pressing priority for 2003. Responses included under this category were fairly diverse. The two most commonly cited priorities focused on the cost or availability of insurance and insuring the uninsured/poor. Five legislators—two from Michigan, two from Washington, and one from Wisconsin--felt small group insurance rates was a priority. Colorado, Kansas and Ohio legislators raised insurance mandates as a priority, with Kansas Representative Patricia Barbieri-Lightner’s committee particularly concerned about “mandates for contraceptives.” Both health chairs from Maine raised universal health care as a concern. Hawaii Senator Rosalyn Baker listed “women’s access to health care” as a priority and Nevada Assemblywoman Ellen Koivisto believes “public employee benefit plans” will fill the agenda in 2003.

Health Care Workforce and Providers

Issues related to the nation’s health care workforce—including provider shortages, access to rural health care providers, licensing of practitioners, scope of practice and staffing issues—were identified as a top committee priority by 29 percent (20) of legislators. Forty percent (8) of these responses related to provider shortages. Connecticut Senator Christopher Murphy believes “regulation of managed care subcontractors” will be a priority of his Public Health committee in 2003, and New York Assemblyman Peter Rivera feels “preventing closure of psychiatric centers” will top this year’s agenda.

Aging, Long-Term Care and Nursing Homes

Aging, long-term care and nursing home issues were again identified as a top committee priority for 2003 by 22 percent of health chairs (15). The majority of these responses pertained to seniors, rather than the disabled. One-third of these responses focused solely on long-term care. Another four dealt with nursing homes, such as Minnesota Senator Linda Berglin’s response, “Preventing transfer of assets for nursing home care.” Three other legislators, from Arkansas, Hawaii, and Pennsylvania, felt issues related to the protection of senior’s rights would dominate the 2003 agenda. Only one legislator, Senator Judy Lee (ND), specifically mentioned, “home and community-based services.” This stands in contrast to last year, when states were actively responding to the 1999 Olmstead Supreme Court ruling, which found that persons with disabilities are entitled to receive care in an integrated setting, state resources permitting.

Medical Malpractice

In 2002, 46 states introduced measures that encompassed some provisional change in existing state law related to tort reform. While the issue of medical malpractice is broad, reaching beyond the jurisdiction of health committees, medical malpractice tied with aging, long-term care, and nursing homes as the sixth most prevalent issue among health chairs (22%). It ranked higher than aging, long-term care, and nursing homes in terms of number of states where it was mentioned as a priority (13 states vs. 12 states). While the cause of the current crisis continues to be debated, medical malpractice legislation is significant in terms of health care because of its direct effect on quality and access to care.

Mental Health and Substance Abuse

Mental health and substance abuse issues weighed in as the seventh highest agenda item among health chairs. Seventeen percent of legislators responding (12) identified mental illness or substance abuse as a top committee priority, slightly higher than last year’s response rate of 11 percent. Legislators from Maine and Vermont specifically noted substance abuse as a priority, while legislators from Michigan and Missouri listed mental health parity as a priority.

Disease Prevention and Management (Conventional Public Health)

Conventional public health measures, including disease prevention and management, tied with mental health and substance abuse as the seventh most frequently cited priority among health chairs. Three legislators identified prevention as a legislative priority. Specific diseases were mentioned by four other legislators from three different states. Arizona Senator Carolyn Allen listed “Alzheimers treatment facilities” as a top concern of her Health Committee; South Carolina Representative Joe Brown spoke of “diabetes school care”; and both the Senate and House leaders of Indiana’s Health Committee spoke of obesity as a priority. Obesity may be more prominent on the health agenda next year, after the Centers for Disease Control and Prevention (CDC) announced in May 2003 that the treatment of illnesses related to obesity costs America $93 billion a year, rivaling the financial toll of smoking-related disease. Three other responses pertained to smoking bans/tobacco prevention (Alabama, Rhode Island, and South Dakota), while Minnesota Representative Lynda Boudreau listed, “immunization/vaccine safety” as a priority.

Bioterrorism and Emergency Public Health Responses

Bioterrorism and emergency public health responses remained a top priority among health chairs, but it dropped significantly in rank this year, with only seven percent (5) of chairs citing it as an agenda item for 2003, versus 27 percent in 2002. All five legislators are from the Eastern seaboard or share a border with Canada (Connecticut, Michigan, New Hampshire, New York, and Wisconsin). States continue to manage federal emergency response funding made available following the September 11^th terrorist attacks and anthrax crisis. Add to the picture SARS and the war in Iraq and it is not surprising that this issue still remains a top priority for state lawmakers.

Administrative Reorganization

During this time of budgetary shortfalls, state legislators are looking about for efficiencies. Seven percent of chairs (5) cited administrative reorganization efforts as a priority, reflecting not only the gravity of the situation but creative policymaking. The majority of these responses reflect departmental consolidations. Other committees, such as Massachusetts Senator Richard Moore’s Health Care Committee, will be examining ways to “coordinate health programs to minimize waste.”

Oral Health

Four percent of chairs (3) listed oral health as a priority. These responses came from legislators in Hawaii, Idaho, and Wisconsin.

Stem Cell Research

Stem cell research tied with oral health as the ninth most prevalent priority among chairs. Three chairs, from Minnesota, New Jersey, and Tennessee listed stem cell research/cloning as a top priority.

Miscellaneous Issues

Among the responses to our survey were individual priorities that did not appropriately fit into any of the aforementioned categories. While these responses were not included in our calculations, they deserve mentioning because they may serve as a prognosis of future trends. Maryland Delegate Marilyn Goldwater listed “Blue Cross/Blue Shield Conversion to for profit” as one of her top priorities, South Carolina Representative Joe Brown cited “alternative and nonconventional medical treatment,” and Missouri Representative Roy Holand listed abortion, in particular the “24-hour waiting period,” as a top priority. New Hampshire Representative Peter Batula noted that the state “developmental disabilities waitlist” is a top concern of his Health and Human Services Committee. While this issue was expressed frequently as a personal concern of legislators, it was recognized as a committee priority only in this one instance. Finally, Minnesota Representative Lynda Boudreau and Texas Senator Jane Nelson raised two separate issues that frequent the headlines, but were nowhere to be found among health chair legislative priorities for 2003—“health record data and privacy issues” and “patient safety.”

Personal Interests

As with committee priorities for 2003, cost and financing issues dominated legislators’ personal interests. Chairs are most interested personally in Medicaid cost issues, access issues, conventional public health (including disease prevention) issues, and health care workforce and provider issues. Connecticut Senator Christopher Murphy has a personal interest in “taking advantage of Medicaid waivers to expand health coverage” and New York Assemblyman Peter Rivera is concerned about “having hospitals provide translation service in emergency rooms.”

Topics related to prescription drug costs, mental health and substance abuse, and to aging, long-term care, and nursing homes were the next most frequently cited personal priorities. Maine Representative Thomas Kane wants to see the “establishment of a national non-profit prescription drug benefits management program,” and Pennsylvania Senator Harold Mowery, Jr. said that he is personally concerned about the “impact of direct-to-consumer advertising on prescription drug costs.” In terms of aging and long-term care issues, community and home-based care was mentioned in about one-third of the responses (5). In contrast, only one legislator cited it as a committee agenda item. General health care costs, medical malpractice, and administrative reorganization were also common personal priorities, but mentioned less frequently than they were under committee priorities.

Personal priorities that were not mentioned as committee priorities include women’s health issues, organ donations, and domestic violence. There also appears to be a growing interest in the elimination of health care disparities, despite the fact that the issue is not yet a top committee agenda. Two chairs explicitly mentioned disparities in health care as a personal priority, including Indiana Representative Charlie Brown, who is also interested in the “recruitment and retention of African-American medical students.”

For additional information regarding this survey call Kala Ladenheim at (202) 624-5400.

This survey was a joint effort of the Health Chairs Project (a collaboration between the National Conference of State Legislatures and the Schneider Institute for Health Policy at Brandeis University) and the Health Policy Tracking Service at NCSL. Funding was provided by the Henry J. Kaiser Family Foundation http://www.kff.org/