Assessing and Promoting the Health of State Health Policy Environments

Segue Consulting recently completed an engagement with the Robert Wood Johnson Foundation to analyze the dynamics of state health policy environments. The goal was to support the Foundation’s efforts to build a "Culture of Health" by identifying ways to promote more effective stakeholder engagement in health policy.  The project was extraordinarily stimulating and continues to impact our thoughts as we synthesize the many changes happening in health care. This is the first of a series of blogs we intend to publish to share what we think we have learned.

During the past year, we studied blue states and red states, Medicaid expansion and non-expansion states, states with a bias toward increasing access to insurance and states more concerned about changing the negative incentives driving the cost of care. We explored both the experiences of states often mentioned in the context of health system reform as well as those that have gotten less attention over the past few years. Importantly, we found that stakeholders in all categories of states had been active on a number of fronts.

Regardless of political orientation, states are anxious about the current instability of the Affordable Care Act and the possibility of significant federal budget cuts to Medicaid.  Some states are taking a “wait and see” attitude, while others are trying to identify how they will sustain ongoing reforms if federal contributions to Medicaid are significantly reduced. Even in states that were early adopters of innovative efforts to transform their systems, the changes are not yet fully engrained, and benefits are still maturing.

We identified five hallmarks of a healthy policy environment that can support health system transformation:

1.       Effective leadership

2.       A culture of trust and collaboration

3.       A level playing field that allows citizen voices to be heard and heeded

4.       Health policy-savvy officials and stakeholders

5.       Access to credible, actionable, state-specific data

While none of these are startling or new discoveries, our research reinforced how important these hallmarks are for any effort to change the health system.  We chose not to define health system transformation. Our initial belief that this should be locally defined was strengthened by this work.

We narrowed our analysis to the latter three hallmarks as we explored possible options to promote healthier state health policy environments. Leadership and culture can be influenced by these three but are longer-term, generally internally-driven changes, less amenable to outside intervention.

The last year has been challenging for professionals committed to a better health system.  However, we discovered opportunity during our work with the states.  For almost a decade, implementing the Affordable Care Act has been a focal point of -- and often overshadowed -- other efforts to create a better health system.  For supporters of the ACA, this created an almost myopic focus on access to coverage; opponents focused on repeal at all costs.  The deep political divisions that ensued have made coverage a politically polarizing landmine.  We do not see this changing anytime soon.

 So, what’s the opportunity, and is there reason for optimism?

During the last decade, public and private, state and regional players have gained experience with other change models.  Unlike the issue of coverage, health system transformation is not yet politically polarized.  This creates enormous opportunity to find areas of agreement.  We found that across the political spectrum, support is growing for:

·         Primary care-centered care;

·         Integrated care;

·         Outcome-based payments;

·         Payment tied to a logical economic model; and

·         Attention to social and economic barriers to health outside of the medical care system.

These address fundamental economic flaws in our health care system.  Identifying mechanisms to address drivers of cost, perverse incentives, and expenditures that are not linked to the most efficient mechanism for providing the service can appeal to conservatives and liberals alike.

There is much we can learn from efforts in states across the country that are focusing on health system transformation instead of access to coverage.  There has been early success in these areas, but much work remains to truly understand how best to implement any of these options in diverse policy, social, and clinical environments. States are likely to receive greater flexibility and authority for Medicaid administration under the Trump Administration. 

The importance of a trigger event to catalyze change was also reinforced by our work with the states.  While the extent of federal budget cuts could jeopardize many of these efforts, there is no question that cuts and the repeal of important components of the ACA will catalyze change.  We will be ready to apply the lessons we have learned about ways to support health system transformation in response to federal action.

Changing our language and our focus to health system transformation does not minimize the importance of insurance coverage as a prerequisite to preventive care, timely diagnosis, and treatment for medical conditions.  However, almost a decade of effort with the ACA has convinced us that we will all be better served to focus on ways to depoliticize efforts to improve our health care system and create an atmosphere where diverse stakeholders can participate equitably in policy deliberations to support health system change.