By Jack Pitsor
State legislatures have long played an important role in bolstering access to high quality, affordable health care services. And as the country continues to confront the COVID-19 pandemic, health care access has only become more vital.
Improving access to care—or the timely use of personal health services to achieve the best health outcomes—can be achieved through many policy avenues, including Medicaid, telehealth and health care workforce capacity.
These issues will be discussed during a session on the first day of NCSL's State Policy 101 at 3:30 p.m. Friday.
Several federal agencies, such as the Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC), are also committed to improving the health of populations by providing data, funding and programs to states and other localities.
This post highlights these three policy areas, relevant state examples and select federal resources for state policymakers aiming to enhance access to health care.
Medicaid—a state-federal partnership with joint authority and financing—is a public health insurance program covering low-income individuals. While the program covers a large share of the U.S. population, it also consumes a large share of state budgets.
Various policy levers are available to state legislators to improve access to care for enrollees, while focusing on financial sustainability for state Medicaid programs. Some of these policy actions relate to Medicaid eligibility, optional benefits and reimbursements to providers. For example:
- Thirty-six states and the District of Columbia expanded Medicaid eligibility typically to individuals with incomes at or below 138% of the federal poverty level, either through traditional Medicaid expansion or special waiver authorities known as Section 1115 waivers. Voters in two additional states—Missouri and Oklahoma—approved Medicaid expansion via ballot measure in 2020, but expansion has not yet been implemented.
- Idaho required its Medicaid program to implement value-based payment models for inpatient and outpatient hospital services.
- Colorado created the Cost Control and Quality Improvement Office for its Medicaid program in 2018. The office aims to address inefficiencies and improve health care quality for Medicaid enrollees.
Many communities, especially rural and remote areas, are experiencing health care workforce shortages, and individuals may have to travel a significant distance to see the nearest health care provider. Additionally, COVID-19 has shifted the way many providers deliver health services and patients seek out those services.
In response, many states are turning to telehealth as a cost-effective alternative to some in-person health care services. Many telehealth state policies touch on private insurance and Medicaid reimbursement, provider licensing requirements, and the types of providers authorized to use telehealth, among other several other topics. For example:
- New Hampshire required private health plans and Medicaid to reimburse providers using telehealth on the same basis that it reimburses for in-person services.
- Florida authorized out-of-state providers, without a Florida license, to deliver services to in-state residents through telehealth.
- Ohio added several provider types—including registered nurses, physician assistants, psychologists, social workers and others—to the list of providers who can deliver services via telehealth.
For legislators evaluating their state telehealth policies, the Rural Information Hub compiled key resources on telehealth funding opportunities, projects and policy updates. CDC also developed a comprehensive resource on telehealth use during the COVID-19 pandemic.
Health Care Workforce
Beyond telehealth, states are assessing other policies to mitigate workforce shortages and improve access to care. For example, many states are streamlining licensing requirements for out-of-state health care providers. One way to do this is through interstate compacts, which are formed when states pass legislation with the same language authorizing interstate practice for various provider types.
Another potential state strategy for enhancing the health care workforce is to evaluate scope of practice (SOP) requirements, which dictate what a health care provider can or cannot do for a patient. Many states have modified SOP for various non-physician providers relating to supervision or oversight requirements, prescriptive authority and other SOP requirements. Some examples relating to licensing and SOP include:
- Kentucky authorized its state licensing boards for physicians, nurses and emergency medical service professionals to waive licensing requirements for out-of-state providers during the COVID-19 emergency.
- North Carolina became the 15th state to join the Psychology Interjurisdictional Compact, which facilitates telepsychology and temporary, in-person services among member states.
- Fifteen states and D.C. authorize nurse practitioners to have full independent practice authority, which allows NPs to practice independently without physician oversight.
HRSA provides key resources relating to the health care workforce, such as its Area Health Resources Files with state-level data on various types of health care providers. Additionally, HRSA operates scholarship and loan forgiveness opportunities to recruit more health care providers to workforce shortage areas.
While states convene legislative sessions amid the challenges of a pandemic, lawmakers may look to other states and federal programs for ideas to assess and support access to care efforts in their states.
Jack Pitsor is a research analyst in NCSL's Health Program.