In a recent survey of legislative priorities, 53 chairs of state health committees, representing 39 states and Puerto Rico, reported their top health priorities for the 2001 session.
1. prescription drug costs and coverage
2. long-term care
3. access to health care.
4. mental health and substance abuse
5. health care workforce
The survey was conducted by the Health Chairs Project, a collaboration between the National Conference of State Legislatures and the Schneider Institute for Health Policy at Brandeis University and was made possible by generous funding from the Henry J. Kaiser Family Foundation. State legislative policy priorities reflect state agendas and influence the national agenda. Recently, states have led the way with health policy initiatives such as managed care protections and pharmaceutical benefits for the elderly. These priorities are particularly interesting now, because the incoming administration has promised to give states a prominent role in shaping policy.
- Prescription drug costs and coverage is the number one priority identified. Forty percent of legislators responding indicated that this topic would be important on their committee agendas, citing "high costs and unavailability" as a major underlying factor. More than half (53 percent) said it was likely that their state would consider enactment or modification of state pharmaceutical assistance program. Advocacy groups for the elderly, as well as groups representing health care consumers with expensive prescription needs, are pushing hard for reform. While twenty-six states currently have some type of pharmacy assistance law, many face funding shortages for their prescription drug benefit programs. Other states, such as Maine and North Carolina, face problems implementing newly enacted legislation.
- Mental Health and substance abuse issues, including parity, funding, service delivery and system design ranked second, with 28 percent of legislators indicating this would be an important committee priority in 2001. Although 23 states currently require full mental health parity for adults, some, such as Oklahoma and Rhode Island, want to expand existing laws to include children. Many states are facing funding shortages in their mental health programs, and some, such as Nebraska, hope to use state tobacco settlement funds to provide or expand services.
- Long-term care issues, including regulation of nursing homes and expansion of community-based services in response to the recent Supreme Court Olmstead holding, ranked third on the list of top priorities, named by 25 percent of legislators. Two of the ten issues most likely to be considered this session were in this category: regulation of nursing homes (49 percent) and expanding home and community based care (55 percent). While several states have already begun to implement and expand community-based long-term care services in response to Olmstead, many others are just now getting on board. Inadequate Medicare funding for nursing homes and community-based health services was also a key area of concern for the upcoming state legislative sessions.
- Workforce issues followed as the fourth most frequently listed agenda item; 21 percent of legislators anticipated that this would be a top agenda priority in 2001, and 45 percent said it was likely to be considered in the 2001 session. Shortages of health care professionals, especially nursing staff were identified as primary concerns.
- Health care access--expanding access to health care for the uninsured and increasing health insurance coverage-- was cited as the fifth most important agenda item for 2001, as indicated by 19 percent of legislators surveyed. Forty-two percent said that expanding eligibility under Medicaid was likely to be considered.
Complete survey results and analysis are available on Henry J. Kaiser Family Foundation website http://www.kff.org/
In a recent survey of legislative priorities, 53 chairs of state health committees, representing 39 states and Puerto Rico, named five issues as their top priorities for the 2001 session:
- prescription drug costs and coverage
- mental health and substance abuse
- long-term care
- health care workforce
- access to health care
The survey was conducted by the Health Chairs Project and the Henry J. Kaiser Family Foundation. More than a third of the 147 state legislators who serve as chairs of health-related committees (e.g., Health and Human Services, Health and Welfare, Public Health, Health subcommittees of fiscal committees) responded to the survey by naming their three top issues.
In addition to the priorities they named, the chairs also selected among 57 issues in more than a dozen categories to indicate which were likely to be addressed in the 2001 legislative session. The top ten issues they picked each received at least 40 percent of their votes.
- Increased funding for/expansion of home and community-based care (55 percent)
- Allocation of tobacco settlement funds (53 percent)
- Enactment or modification of state pharmaceutical assistance programs (53 percent)
- Regulation of nursing homes (49 percent)
- Supporting healthy schools (47 percent)
- Shortages of certain health professionals--nurses, nurse aides (45 percent)
- Reporting of medical errors or health plan performance (43 percent)
- Expanding eligibility under Medicaid (42 percent)
- Tobacco control (43 percent)
- Violence prevention in schools (41 percent)
Respondents reflect the national political make-up. They split evenly by party affiliations: 49 percent are Republicans (26), 49 percent are Democrats (26), and one is a member of the New Progressive Party (Puerto Rico). Fifty-three percent of respondents are Senators (28); 47 percent Representatives/ Assemblymembers (25).
Health committee chairs play a critical role in setting state health policy agendas and are integral figures in the establishment of health care initiatives and legislation. The 147 health-related committees in state legislatures review legislation proposed by other legislators, identify emerging policy issues and introduce new bills. State-level debate and legislation on urgent priorities such as pharmaceutical benefits for the elderly and patient protection have set the stage for federal deliberation on these issues.
This survey consisted of two distinct parts. Part I required written responses. Legislators were asked to rank and identify the three issues that they expected to be most important in their committee during the 2001 session and were asked to follow up with a brief explanation of why they selected their number one issue. In addition, legislators were asked to cite any issues that they believed would come before their committee as a result of federal actions or inaction. Finally, legislators were asked to list the top two health-related issues that they are most personally interested in. Although several issues listed as top agenda items overlapped (i.e., tobacco settlement and mental health services funding; tobacco settlement and prescription drug funding, prescription drug costs and health care costs), each issue was counted only once in the final data tabulation. For Part II of the survey, legislators were given a menu of issues (see attachment A for issue headings) and were asked to determine the likelihood that each issue would be the subject of committee action or debate in the 2001 session.
Fifty-four percent of legislators responding (28) identified pharmaceutical issues as a top committee priority, an expected agenda item due to federal action or inaction, or an area of personal interest. Forty percent of legislators (21) indicated that prescription drug costs and coverage issues would be a top priority in their committees in 2001. Members representing East Coast states (Connecticut, Maryland, Maine, New Hampshire, New York, North Carolina and Rhode Island) weighed in especially heavily on the issue. Thirty-three percent (17) also believed that pharmaceutical issues would come before their committee as a result of federal actions or inactions and 13 percent (7) listed this as an area of personal interest.
Several of these states are among the twenty-six that have taken steps (either through state laws or executive mandates) to provide some type of prescription drug assistance to eligible seniors and individuals with disabilities. Some, such as Minnesota, New York, North Carolina and Rhode Island, use state funds to subsidize part of consumer costs through pharmacy assistance programs. Other states, such as Iowa, New Hampshire, Washington and West Virginia have established discount purchasing cooperatives, which utilize pharmacy benefit managers to negotiate with pharmacies to provide lower prescription rates for consumers. Connecticut and Vermont are among a number of states that offer a combination of the two approaches. Maine and Maryland, which have had prescription drug benefit programs in place since the 1970s, are now working to expand their programs and identify new funding sources. Maine was one of the first states to create a senior pharmaceutical assistance program and currently has one of the most comprehensive laws, which includes mandatory bulk purchasing and potential price regulation. This state's Prescription Drug Price Reduction Act was recently enjoined from implementation by a federal court in response to a challenge by the pharmaceutical industry; the outcome of this case may help to determine how far states can go in enacting future prescription drug legislation.
As one health chair from Connecticut noted, "prescription drug coverage [is an] issue of concern throughout the Northeast..." Other legislators identified prescription drug coverage as "the dominant economic issue of the campaign" and felt that this is slated to be a "major national political issue" that must be addressed at the state level.
Legislators representing states that have discount mandates but no formal pharmacy subsidy laws, such as Missouri and Washington, noted that the "high costs and unavailability have driven many groups to push for reform". "Senior lobby and citizen action" groups are making prescription drug coverage a prominent legislative issue. Advocacy groups for the elderly, such as AARP, as well as groups representing health care consumers with expensive prescription needs, are perceived as the main impetus behind this agenda item.
Mental health and substance abuse issues including parity, funding, service delivery and system design followed as the second most frequently listed agenda category. Overall, mental health and substance abuse issues were identified as a top committee priority, an expected agenda item due to federal action or inaction, or an area of personal interest by 37 percent of legislators (19).
Twenty-eight percent of legislators (15) also stated that this would be an important committee priority in 2001. While mental health issues are expected to be a pressing agenda item in the upcoming state legislative sessions, only 6 percent of legislators (3) believed that such issues would come before their committee as a result of federal actions or inactions. Twenty-three percent of legislators (12) listed mental health and/or substance abuse issues as areas of personal interest. It should also be noted that mental health was mentioned most frequently as a separate issue; only one legislator identified mental health and substance abuse together as an expected priority. This is perhaps an indication that legislators are just beginning to view these two areas as part of a combined agenda issue.
Twenty-three states currently have some form of mental health parity legislation. Rhode Island and Oklahoma are working to develop a system of care for children. The Oklahoma legislature plans to push for full parity by extending its current law, which covers biologically-based mental illnesses only. Legislators from states that currently lack parity legislation, such as Arkansas, Iowa and Michigan, identified parity as a top committee issue for the 2001 session.
Many states are currently facing funding shortages in their comprehensive mental health programs. Montana, for example, faces a $15 million deficit in the state mental health program. Funding for mental health services was another prominent theme among legislators from states such as Arizona and Nebraska. Nebraska, in particular, hopes to use state tobacco settlement funds to augment existing services. Legislators from other states (such as California and Michigan) identified expansion of existing state mental health services as a predominant priority.
Members of the children's' health advocacy and mental health advocacy communities are urging states to implement parity initiates and expand existing programs.
Long-term care, including community-based service expansions, was identified as a top committee priority, an expected agenda item due to federal action or inaction, or an area of personal interest by forty-two percent of legislators (22). Long-term care was also high on the agenda, with 25 percent of legislators (13) stating that this would be a top committee item in 2001. Seventeen percent of legislators (9) indicated that long-term care issues would come before their committee as a result of federal actions or inactions and 21 percent of legislators (11) listed some aspect of long-term care as an area that they were personally interested in.
As a result of the recent Supreme Court Olmstead v. L.C. holding, many states have intensified their efforts to implement and expand community-based long-term care services. Legislators from two states, Louisiana and Texas, specifically noted that compliance with the Olmstead decision will be a top priority in 2001. Legislators from four other states (Missouri, Nebraska, North Carolina and Washington) indicated that Olmstead-related issues are likely to come before their committee as a result of activity or inactivity at the federal level.
Maine is one of several states now waiting to see how implementation of recently enacted long-term care reform legislation will proceed. Arizona joins a growing number of states that will face the dual challenges of system design and funding as they strive for compliance with the Olmstead decision. The Arizona legislature convened a task force last year to address long-term care issues; follow-up from this is likely to spur committee activity in 2001. Legislators from Arizona, South Dakota, Texas and Washington are among those that believe funding for nursing homes and community-based health services will be top priorities in 2001. One Mississippi legislator also indicated that increasing insurance liability for long-term care facilities would be a pressing issue during the upcoming year.
As with mental health reform, advocacy groups are pushing states to investigate alternative options to institutional care and were cited as the main groups likely to be responsible for elevating this issue to the 2001 agenda.
Overall, workforce issues were identified as a top committee priority, an expected agenda item due to federal action or inaction, or an area of personal interest by 23 percent of legislators (12). Workforce issues were also listed as a top committee concern by 21% of legislators (11). This fourth place ranking was a result of concerns about shortages of health care professionals and nursing staff to patient ratios. Only four percent of legislators (2) indicated that workforce issues were likely to come before their committee as a result of federal actions or inactions; the same percentage of legislators listed this as a personal interest.
Legislators from Minnesota, New Hampshire, Ohio and West Virginia cited issues related to health care staffing ratios (either long-term care and nursing home staffing or general staffing issues) as a top committee priority for 2001. Nurse and other medical provider shortages were viewed as a pending priority for three states, Arkansas, Connecticut and Indiana. A legislator from South Carolina gave the only indication that scope of practice issues would be a top policy priority, stating that this is "always an issue for [my] committee.... several allied health professional groups routinely seek expansion of their scope of practice".
Finally, issues related to health care access were identified as a top committee priority, an expected agenda item due to federal action or inaction, or an area of personal interest by 25 percent of legislators (13). Health care access was seen as a likely agenda item by 19 percent of legislators surveyed. Only one legislator indicated that health care access would come before the committee as a result of federal actions or inactions, and 13 percent of legislators (7) listed this issue as one that they were personally interested in.
Legislators from California, Maine, Missouri, Montana and West Virginia specifically indicated that expanding access to health care for the uninsured and increasing health insurance coverage would be top priorities in 2001. Health Committees in North Dakota and Washington and are also likely to face health care funding and financing issues on their 2001 agendas.
It is also interesting to note that health care cost (identified by legislators as cost to consumers, cost control or health care inflation) was listed as an important agenda item, despite the fact that this was not anticipated at the onset of survey design and therefore not included as a separate category in Part II of this survey. Ten percent of legislators (5) cited "health care costs," resulting from rising insurance premiums over the past several years, as an expected priority on their committee agendas in 2001. Legislators from Minnesota, New Jersey, North Carolina, Vermont and Washington specifically identified cost as a pressing issue. Employer and consumer advocacy groups were cited as the main groups currently pushing for reform.
According to results from the second half of the health chairs survey, the top 10 issues legislators expect to see on their committee agendas in 2001 are:
- Increased funding for/expansion of home and community based care (55 percent)
- Allocation of tobacco settlement funds (53 percent)
- Enactment or modification of state pharmaceutical assistance programs (53 percent)
- Regulation of nursing homes (49 percent)
- Supporting healthy schools (47 percent)
- Shortages of certain health professionals--nurses, nurse aides (45 percent)
- Reporting of medical errors or health plan performance (43 percent)
- Expanding eligibility under Medicaid (42 percent)
- Tobacco control (43 percent)
- Violence prevention in schools (41 percent)
While the responses in Part II mirror those given in Part I, several interesting nuances emerge when the data is examined in more critical detail. For example, while the broad category of health care access is actually identified as a top three agenda item by only ten legislators (19 percent), 42 percent identified a subcategory under Access in Part II, "expanding eligibility under Medicaid", as an issue likely to see federal action or debate in 2001. Interestingly, another subcategory of this broader access topic, "new tax policies, [such as] credits or medical savings accounts (MSAs)" was ranked as an unlikely agenda item by 40 percent of legislators.
Other important trends involved pharmaceutical issues and medical errors. Fifty-three percent of legislators felt that "enactment or modification of state pharmaceutical assistance programs" was likely to come up during the next session, and 34 percent answered similarly with respect to "incentives for generic drug use in state-funded programs or private insurance". Reporting of medical errors also appears to be an area of growing concern for legislators. Forty-three percent of legislators ranked "reporting of medical errors or health plan performance" as a topic likely to be addressed during the 2001 session. While other areas of consumer protection (such as enacting or expanding Patients Bill or Rights) did not rank high on the list of likely agenda items, medical errors stood out as a lone issue for legislators, possibly an indication that this remains an area of consumer protection that requires further remedy.
Part II provided interesting information about what was not likely to appear on state health agendas. State Children's Health Insurance Programs (SCHIP), women's health and health insurance regulation received relatively little attention. Only 10 percent legislators felt that "insurance mandates related to reproductive health" and "osteoporosis screening and mandates" would be likely agenda items in 2001. Similarly, "changes in reimbursement" for SCHIP services not currently covered was cited as a likely agenda item by only 8 percent of respondents, and as many as 45 percent legislators indicated that "expansion of income level covered" was unlikely to see legislative action.
Charts & Graphs -- HTML
Charts & Graphs -- PowerPoint
This survey was conducted by the Health Chairs Project, a collaboration between the National Conference of State Legislatures and the Schneider Institute for Health Policy at Brandeis University and was made possible by generous funding from the Henry J. Kaiser Family Foundation.
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