February 9, 2022
10 State health policy changes that should outlive COVID-19
By Josh Archambault
The COVID-19 pandemic highlighted many of the barriers in healthcare that make care less patient-centered, more expensive, and more difficult to access. State policymakers should learn from this and remove these barriers permanently.
In all states, Republican and Democrat governors waived barriers during the pandemic to help respond, but the need for more flexibility is long overdue. Policymakers must step back and reevaluate how to ensure our health system is ready for the next pandemic. But making the right changes now would have the added benefit of saving significant money for patients and small businesses struggling to afford healthcare and coverage. It is not an understatement to say the health—both physical and economic—of our states depends on taking meaningful action now.
1. Best practice telehealth expansion
The pandemic demonstrated the many benefits of telehealth. While they can and should not replace all in-person medical appointments, virtual visits can save patients time and help them avoid germy waiting rooms. Providers cut down on their risk of exposure and can see more patients from an office or home. To experience the full potential of telehealth, states should follow these best practices.
Do
Don’t
2. Allow providers to use their full education and training (i.e., liberalize scope of practice)
Access to medical providers is acute in many communities, yet most states don’t allow a provider that has been trained in certain procedures or services to offer them. Liberalizing scope-of-practice laws would allow a nurse practitioner (NP), for example, to see patients independently for all services they have been trained to offer. In the roughly half of states that don’t allow independent practice for NPs a patient is often still charged the doctor’s rate to see an NP.
States should sunset any scope limitation that is not backed up by robust research showing quality concerns, and liberalize rules across the care spectrum for NPs, physician assistants, pharmacists, and for all technicians and aides to extend the health workforce. During the pandemic, waivers for more flexibility were key to meet the health needs in many states. The alternative in many communities is for patients to receive no care or to wait months for an appointment for needed care.
3. Repeal or scale back the government permission slip process for health system flexibility
Certificate-of-need (CON) laws and regulations require a government permission slip for changes for certain capital expenditures for a new facility, adding beds, a renovation, some changes in services, or a transfer of site of care. These laws artificially restrict the variety and number of care settings and equipment that can be utilized to treat patients. Federal officials in both Democrat and Republican administrations have urged states to repeal or reduce their CON laws since they reduce competition, result in higher prices and lower quality care for patients. During COVID-19, states without CON laws were found to have fewer hospital deaths, as this flexibility helped them better treat non-COVID-19 patients as well.
4. Allow patients to be seen by the same provider regardless of location
Pilots can take off from one state, cross a state line, and we don’t assume they have lost their skills or prevent them from taking off again. Yet our licensing system for our medical professionals assumes that pandemics and skills stop at a state border.
States should allow any providers in good standing in their primary state of practice to be able to register with any relevant board or commission in a given state, and be granted a full license not only to practice telehealth, but also to see patients in person in that state to provide needed care. Compacts are not enough, and in an increasingly mobile nation, not allowing across-state-line care hurts outcomes for patients and a continued provider relationship, and decreases access.
5. Protect medicaid resources for the truly needy
Medicaid is the largest line item in most state budgets and crowding out other public priorities. In 2020, more than one in four dollars spent on Medicaid was improper. One of the largest problems is improper enrollment. Most states do a poor job properly verifying income, residence, incarceration status, or even if enrollees are still living. In managed care states, for every ineligible enrollee, taxpayers are simply increasing the bottom line of insurers at the expense of K-12 education, roads, and public safety.
States must prepare for the end of the COVID-19 public health emergency by beginning to conduct eligibility redeterminations, as they stopped during COVID-19, so states can stop paying insurers for ineligible enrollees when reviews kick back in. States should also evaluate if the extra federal matching COVID-19 Medicaid funds outweigh the increased state costs from covering ineligible enrollees, and pull out if they are costing more.
6. Get patients full price transparency
Whether treating COVID-19-related symptoms, or other conditions, patients are putting off care due to concerns over unknown prices. Building off recent federal regulations on price transparency, states should take the next steps to ensure a competitive market that is a win-win for high-value providers and their patients. Price transparency should be:
Finally, patients should be able to access lower-cost care out of network, and receive credit toward their deductible since they saved everyone money, and get referred back in-network as needed without penalty. These reforms finally help align incentives to deliver high-quality care for less.
7. Offer new coverage options such as farm bureau style plans
Due to the ever-increasing cost of health insurance, fewer businesses are offering it to employees, and many are dropping coverage in the individual market. During COVID-19, this has added an extra burden for millions of Americans. Several states, including Indiana, Iowa, Kansas, South Dakota, Tennessee, and Texas offer a different approach. These states allow their statewide farm bureaus to offer health coverage options that are exempt from state insurance regulations. These plans are 30 to 50 percent less expensive, while coverage remains robust, featuring statewide networks, free or low-cost preventative care, and options for many additional benefits. The plans are also guaranteed renewable even if they get sick, and can stay with the enrollee even if they switch jobs. States should allow well-established and trusted industry groups to offer residents these new options.
8. Push back on federal overreach
A federal administration change can result in a steady stream of agency guidance, dear colleague letters, and “governing” by a blog post that makes their policy preferences sound like rule of law.
For instance, current federal agencies communicate directly with state agencies (unbeknownst to the governor or legislature) and push the agency to make a change by threatening a significant loss of funds or some sort of legal action if the agency fails to comply. Too many state agencies fail to scrutinize the federal law under which the federal agency is claiming to exert its authority.
State legislatures and governors’ offices should be asking to see or be briefed on these behind-the-scenes letters that attempt to change current policy or attempt to tie strings to money to ensure that state policymakers are making the policy in the state, not unelected federal agency bureaucrats. Areas to start with that are COVID-19-related or tied to economic recovery from COVID-19 could be unemployment insurance, Medicaid, and food stamps.
9. Update state employee health coverage
States spend significant resources on health coverage for active and retired public employees. Yet most states are missing huge opportunities to improve the care provided to employees, and save significant funds for taxpayers and the state budget in the process. Put another way, states are overpaying millions of dollars every year for low-quality care that harms the health of their employees and holds the health system back from reorganizing to deliver the best care possible during a pandemic.
Paying employees shared savings when they receive care from less expensive providers and moving to use reference-based pricing for common procedures will remove overly expensive and lower-quality care options. States that have pursued one or both of these have saved millions with happy employees as they have the tools needed to be financially rewarded for getting the right care at the right locations.
10. Protect the doctor-patient relationship
Arrangements such as direct primary care, where a patient pays a provider a set monthly fee, were largely unaffected during the pandemic as the rest of the health care system shut down or struggled to adjust. States should embrace such models by passing or expanding current laws to allow for more direct medical relationships, allow them to refer a patient with insurance to an in-network provider as needed (insurers often reject these referrals and force the patient to duplicate appointments), and limit hospital non-compete contract provisions to allow patients to stay with their doctor if they leave the hospital. The best response to COVID-19 to ensure patients get the preventative and proactive care they need is to strengthen their tie to their providers.
Reform is needed now
States have spent years talking about the need to reform our healthcare system. It would be counterproductive to pass up this moment to not codify the flexibilities that result in more patient-centered care.
Not pursuing change comes at a cost, less access to care, and a return to many pre-pandemic practices that drive up costs and lower the quality of care delivered.
