States not shying away from reforming health care

Sep 04, 2024

Presented by

Driving the Day

Hospital workers care for a patient.

With Congress failing to take on most major health policy issues this session, states have taken to passing their own health care legislation. | Mario Tama/Getty Images

OUTSIDE THE BELTWAY — With a tightly divided and historically unproductive Congress since early last year, states are still taking plenty of action on health care legislation.

So far, this Congress has enacted more bills that rename post offices (seven) and VA clinics (five) than bills that address health care (10) — none of which gave rise to major policy changes, except for a restructuring of the organ transplant system. More substantive lawmaking, including adding transparency requirements for pharmacy benefit managers, could come post-election.

Tahra Johnson, director of the National Conference of State Legislatures’ health program, said the number of health care-related bills has doubled since 2018.

With most state legislatures having wrapped up their work for 2024, here are some top trends in state legislating this year:

Workforce: More than 450 bills related to the health workforce were enacted in 2024, with about half related to licensure and certification, according to NCSL, amid workforce shortages and worker burnout across the sector.

States have boosted payment rates, expanded certain types of providers’ scope of practice and weighed loan forgiveness, said Hemi Tewarson, executive director of the National Academy for State Health Policy.

Pharmaceuticals: Twelve states enacted legislation to lower drug costs by reining in the pharmaceutical middlemen, or PBMs, that manage prescription drugs for health insurers, according to NASHP. Eighteen weighed legislation related to prescription drug affordability boards, though just Vermont enacted legislation establishing such a watchdog to lower drug costs, according to NASHP.

Behavioral health: States enacted at least 158 bills to address drug overdoses and suicide and bolster access to substance use disorder treatment, Johnson said.

Hospital scrutiny: United States of Care, a left-leaning group that advocates for better health care access, noted that more than a dozen states weighed legislation to lower hospital prices, including addressing consolidation, including in “red and purple” states.

What to watch in 2025:

— Medicaid adjustments: As enhanced pandemic-era Medicaid funding has wrapped up, states will have to grapple with more constrained budgets, Johnson said.

— Artificial intelligence: Many states enacted legislation around AI, specifically in health care, Johnson said, but many lawmakers are “still wrapping their heads around” the technology.

— Oversight: Some states have asked NASHP for model legislation on the oversight of the health care business, including ownership changes and consolidation, Tewarson said.

— Telehealth: Expect lawmakers to continue to weigh the future of telehealth, Tewarson said.

WELCOME TO TUESDAY PULSE. We’re mourning the loss of the Rayburn House Office Building’s &pizza. Send your tips, scoops and feedback to bleonard@politico.com and ccirruzzo@politico.com and follow along @_BenLeonard_ and @ChelseaCirruzzo.

A message from Tobacco-Free Kids Action Fund:

E-cigarettes have gone from bad to worse. They come with fun flavors, more nicotine than ever and even built-in video games. Some vapes have as much nicotine as 20 packs of cigarettes. Almost all are illegal. To protect kids, the FDA and other federal agencies must act now. Learn more.

CAMPAIGN 2024

STRONG SWING STATE SUPPORT FOR ABORTION RIGHTS — A new poll of U.S. adults in key states — Arizona, Georgia, Michigan, Nevada, Pennsylvania and Wisconsin — shows that significant majorities of Democrats and Republicans oppose criminalizing abortion before fetal viability.

Bipartisan majorities of US adults in swing states oppose criminalizing abortion before fetal viability

The poll, conducted by the University of Maryland’s Program for Public Consultation and released Wednesday, is a good sign for proponents of ballot measures in Arizona and Nevada that would prevent the state from criminalizing abortion before viability. At least 69 percent of Republicans and 90 percent of Democrats in those two states opposed making abortion a crime before viability.

The results also support Democrats’ moves to lean into abortion rights as a key issue in the 2024 elections, which will likely come down to a small group of states, including those polled.

The methodology: Before they asked the question about criminalized abortion, pollsters explained to respondents that criminalizing abortion meant prison time or fines for the patient or doctor and offered “strong arguments” on both sides.

Respondents from opt-in panels weighted by demographics to match the general population were given the option of criminalizing abortion at different stages of pregnancy: at all stages, only after 15 weeks, only after fetal viability or not at any stage. Each state had a sample size of about 600 and a margin of error between plus or minus 4.2 and 4.8 percent. The poll was conducted between June 18 and July 3.

The overall survey was of 4,957 adults with a margin of error between plus or minus 3.2 percent.

Other takeaways:

— Majorities of both parties in all the swing states surveyed except Republicans in Nevada (48 percent) favor a federal law governing abortion. That suggests President Donald Trump’s messaging that abortion rights might run into some headwinds in swing states.

— Requiring providers to show an ultrasound of the fetus to a patient before an abortion has some bipartisan appeal in the six swing states surveyed. Between 52 and 66 percent of Republicans in the states favored such a requirement, as did between 26 and 49 percent of Democrats.

In the Courts

SCOTUS GIVES BIDEN A WIN — The Supreme Court shot down on Tuesday Oklahoma’s attempt to claw back millions in federal family planning grants that the Biden administration had rescinded after the state refused to provide information on abortion to patients who request it, POLITICO’s Alice Miranda Ollstein reports.

Three conservative justices dissented, saying they would have ruled the other way.

The bigger picture: The move continues the court’s trend since its conservative majority overturned Roe v. Wade in 2022 to sidestep major abortion questions, including narrow procedural decisions this past term on abortion pills and emergency abortions that avoided the merits of both cases.

The court’s decision to deny Oklahoma’s injunction request won’t end the battle over the Title X family planning program, which is playing out in multiple federal courts.

Title X clinics provide contraception, STD testing, prenatal care and other services to millions of low-income people. Under the Biden administration rules, the clinics are required to offer counseling for pregnant patients about all their options, including abortion. Title X funds may not be used for abortion services.

Oklahoma sued the administration last year after it lost roughly $4.5 million in annual funds for refusing to comply with the requirements, arguing that it shouldn’t have to follow those rules because HHS created the regulations, not Congress.

A message from Tobacco-Free Kids Action Fund:

HEALTH INSURANCE

QUESTIONS OF QUALITY — As enrollment in the Obamacare marketplace plan has increased, buoyed by premium subsidies for middle- and low-income people, plan quality has fallen, the conservative Paragon Health Institute wrote in a new report.

The think tank found that the share of consumers in plans with broad provider networks dropped from 36 percent in 2014 to 11 percent in 2023, and premiums have risen faster than those in employer plans. A recent KFF report found that most marketplace-plan enrollees were in plans that have less than half of local doctors in their network.

And middle-income enrollees have been more likely to pick a lower-level plan than previously, the group found.

Why they say it’s happening: The group said the Affordable Care Act's risk adjustment program pays insurers too much for lower-income enrollees.

“We’re seeing a race to the bottom in plan quality,” said Brian Blase, Paragon’s president and a former Trump policy adviser. “Risk adjustment is not adequately accounting for the fact that low-income enrollees are using much less health care.”

Paragon said subsidies’ design reinforces diminishing plan quality.

James Swann, a spokesperson for insurer lobby AHIP, said that surveys show marketplace consumers are “satisfied with their coverage.”

CMS didn’t respond to a request for comment.

Zooming out: The move comes as Democrats and Republicans spar over the future of expanded premium subsidies, which expire at the end of 2025. Democrats are pushing for them to be extended, while Republicans are pushing to let them expire.

“We would not trade [the recommendations] in the report for an extension,” Blase said. “We view this as a substitute policy … that will improve the ACA.”

At the White House

WANT LIST: WASTEWATER, ORGAN FUNDS IN CR — Response to the respiratory illness season, wastewater surveillance and the organ transplant system overhaul could be disrupted if Congress doesn’t include additional funding for HHS in a stopgap continuing resolution, according to a White House document obtained by POLITICO.

Congress has until Oct. 1 to pass a spending bill to avoid a government shutdown, but a stopgap bill, or CR, to punt the deadline for a longer-term bill appears more likely in the coming weeks.

In its request, the White House asked for:

— An additional $50 million to support the CDC’s respiratory virus preparedness and response.

— $20 million to support the CDC’s wastewater surveillance program, which monitors for Covid, mpox and seasonal and avian flu.

— $13 million to restructure the nation’s organ transplant system — a move Congress approved a year ago.

WHAT WE'RE READING

CNN reports on what the science says about soft-shell football helmets.

POLITICO’s Carmen Paun reports on Bavarian Nordic rejecting criticism that its mpox vaccine is too pricey amid a deadly outbreak in Africa.

A message from Tobacco-Free Kids Action Fund:

Parents pleading: the FDA must protect kids.

E-cigarettes are more addictive and kid-friendly than ever. These products contain unprecedented levels of nicotine — some have as much nicotine as 20 packs of cigarettes.

Over 2.1 million kids use e-cigarettes, and 90% use flavored products — almost all of which are illegal. Now, with students heading back to school, we are calling on FDA and other federal agencies to take action. It's time to protect kids and remove all illegal products from store shelves.

Learn more.