“The exceptional caliber of work the NHC is engaging in and the great coalition of organizations it brings together. I truly appreciate[d] the opportunity to join you all.”

– A key takeaway noted by a Roundtable attendee in NHC’s post-event survey

The NHC hosted its first Federal-State Policy Roundtable on Tuesday March 7, 2023, which was attended by nearly 80 federal and state policy staff from NHC member organizations across the country. Following is a summary of the presentations, panel discussions, and breakout sessions.

State Health Politics & Policy and the Intersection with Federal Health Policy

Guest Speaker:

• Kelly Hughes, Associate Director, Health Program, National Council of State Legislatures (NCSL)

NCSL’s Executive Committee, which met in December 2022 and represents state legislators and staff, highlighted health care workforce – across the board and in all sectors – as the biggest policy topic of 2023. Homing in further, the top three priorities for state legislators are: health care workforce; behavioral health, which includes both mental health and substance use disorder; and maternal health. In addition, there are perennial issues that require continuous attention at the state level, and these include: Medicaid; prescription drugs; and cost, access, and affordability. The following provides a deeper dive into some of the specific policy issues that are seeing state-level legislative activity so far this year.

Access to care: Many states are looking at a number of strategies to address access to care issues including: coverage, both Medicaid and commercial insurance, as coverage really facilities entry into the health care system; services such as preventative, specialty, method of delivery, quality of care, etc.; timeliness, including how people get care when they need it; and workforce issues such as finding capable, qualified, culturally competent providers in locations where they are needed.

Workforce: Some of the trends, methods, and policies states are focusing on to enhance and expand the workforce include training and certification through education requirements and continuing education; licensure; scope of practice including practice authority and prescriptive authority; telehealth through broadband access and reimbursement; and recruitment and retention via loan repayment and forgiveness, tax incentives, and career pathways.

Telehealth: Widespread changes to state policy to facilitate access during the pandemic undoubtedly spurred the adoption and use of telehealth across the country. But with many of these changes tied to states’ public health emergency declarations — several of which have ended — states must now decide what telehealth policy will look like moving forward.

States have a lot of flexibility and are looking at policies establishing payment parity, adding specific providers, modifying provider prescribing rules, and clarifying modalities for reimbursement. For example, 17 states reimburse for several modalities through Medicaid; 43 states and the District of Columbia have telehealth private layer laws.

NCSL is also seeing activity in cross-state licensure, where there are currently 165 bills pending, with many states streamlining by joining compacts, of which there are eight at present. Additionally, there has been a lot of activity around telehealth-specific licensing; 25 states have licensing or exemptions right now, an 11-state increase since spring of 2022.

Health system concentration and consolidation: With both horizontal and vertical consolidation on the rise, states are enhancing oversight of mergers and acquisitions and more closely studying health care costs and pricing. Strategies states are pursuing include transaction notice and approval requirements, anti- competitive contract terms, leveraging certificate of need programs, and certificate of public advantage programs.

Surprise billing and medical debt: Unpaid medical bills are the top source of debt for Americans. State-level activity in response to the No Surprises Act is high, with 22 bills introduced in 15 states so far. For example, Kentucky is looking to implement medical debt protections, and New York is seeking to protect individuals from certain penalties like liens and wage garnishment.

Prescription drug reform: This is an issue that tends to be met with bipartisanship, and there is significant activity at the state level, with more than 500 bills introduced already. Other developing trends are related to insulin for which a number of states are looking at copayment limits, including Oklahoma and Rhode Island that are proposing capping copays for diabetic supplies; and to PBMs, with over one-third of all legislation proposed at the state level so far on providing more oversight, PBM transparency and other issues related to PBM activities. Other prescription drug-related issues and trends NCSL is seeing include importation, analyzing prices, and gold card legislation to streamline utilization management.

Medicaid: Because states need to balance their budgets annually, Medicaid is always something state legislatures are concerned about, and 2023 is proving to be no different. More than 2,000 bills related to Medicaid have been introduced so far this year. Medicaid unwinding is a major issue – particularly as the continuous requirement provision is scheduled to end April 1, which may result in as many as 3.8 million people becoming uninsured – and states are looking to improve health insurance outreach and enrollment in response.

States have also taken steps to leverage the Medicaid program to address maternal and child health. Many states have expanded or are planning to expand coverage from six to 12 months. States are also taking steps to address social drivers of health and behavioral health.

Population Health: Key issues getting attention relate to vaccines, with more than 600 vaccine-related bills in 47 states introduced so far this year; the opioid crisis and fentanyl including access to treatment, naloxone, and harm-reduction resources; mental and behavioral health with a number of states looking at issues related to the funding and implementation of the 988 hotline, and increasing access in rural areas, supporting the behavioral health workforce, providing services and correctional facilities; adverse childhood experiences; and maternal and child health including expanding doula and midwife care, clarifying or modifying licensing requirements, and extending post-partum coverage.

View speaker slides here.

Reactor Panel of NHC Members

Moderator:

• Eric Gascho, Senior Vice President, Policy and Government Affairs, National Health Council

Panelists:

• Anna Hyde, Vice President of Advocacy and Access, Arthritis Foundation
• Jennifer Rosen, Senior Director, State Affairs, Alzheimer’s Association

State and Federal Policy Professionals from NHC member organizations shared their reactions to the state policy trends shared in the previous session and gave an overview of their state teams’ top 2023 priorities.

Top Issues. When asked to share their thoughts on what issues are of greatest concern to their organizations this year – based on the issues put forward by Kelly Hughes at NCSL – the panelists made specific note of both access to care, which have been exacerbated by the pandemic, and prescription drugs. They also agreed on the need for policymakers to look at the issues facing the U.S. health care system more holistically because many, if not all, of the issues, while diverse, are all related.

Biggest Opportunities. Ms. Hyde identified emphasizing better, more streamlined access to care as a big opportunity, noting that “Gold carding” is gaining traction and is happening with prior authorization reform. If this is done well it can enable providers to learn from best practices. Ms. Rosen thinks the biggest opportunity comes from the desire of lawmakers to get legislative “wins” from incremental changes. She shared how the Alzheimer’s Association is working to influence state government infrastructures by getting them to direct a specific agency to “own” an issue like Alzheimer’s. It then forces the agency to work with groups like theirs, and it is an effective way to open dialogue and call attention to key policy proposals.

Biggest Threats. Ms. Rosen named the unpredictability of the Centers for Medicaid and Medicare Services (CMS) as the biggest threat, noting that CMS recently refused to cover an approved drug for the first time. Ms. Hyde named the cost of health care as the biggest threat because it is the major driver of patient adherence, and it cuts across a myriad of issues.

Key Takeaways from Breakout Sessions

Participants were divided into small, facilitated breakout groups to share their perspectives on the previous sessions and on the key issues, biggest opportunities, and biggest threats facing their organizations. Some common themes emerged.

• Top issues
  • Medicaid unwinding – now and going forward;
  • Telehealth;
  • Workforce shortages;
  • The impact of the Dobbs decision on all health outcomes;
  • Coverage, access, and affordability
• Opportunities
  • The elevation of the patient voice;
  • Legislators’ openness to non-traditional opportunities (e.g., telehealth resulting from the pandemic experience);
  • Medigap plans;
  • Gold carding;
  • Mandatory waiting periods to get health insurance
• Threats
  • Medicaid unwinding;
  • The polarization of public and reproductive health;
  • Hospital pricing and consolidation

NHC Member Panel on Operations

Moderator:

• Jennifer Dexter, Vice President, Policy, National Health Council

Panelists:

• Lucy Culp, Executive Director, State Government Affairs, Leukemia & Lymphoma Society
• Lynn Albizo, Vice President of Public Policy, Immune Deficiency Foundation
• Jamie Sullivan, Senior Director of Public Policy, EveryLife Foundation for Rare Diseases

A panel of state and federal policy professionals from NHC member organizations shared their experiences and best practices in creating a seamless state-federal partnership on topics ranging from managing grassroots, prioritizing resources, sharing research and information, and communicating issues between the state and federal decision makers.

Organizational Structure. Structures differed significantly based on the size of the team and the organization. Ms. Culp shared that what works for the Leukemia and Lymphoma Society is a matrixed approach – with each team member having overlapping priorities and responsibilities – but one agenda, one set of priorities, and one set of goals; this helps the team stay cohesive and coordinated. Ms. Albizo’s team at the Immune Deficiency Foundation is small, with one state director, one grassroots specialist, and one payer expert, plus a federal lobbyist on whom they lean heavily. Ms. Sullivan shared that EveryLife Foundation has a team of four, plus a program manager, with everyone touching state-level work; policy is developed by a Community Congress of their members. While they are still figuring best practices out, communication is the glue that ties it all together.

Managing Information Flow. Ms. Sullivan noted it is still a work in progress at EveryLife Foundation, but they are finding some success in having their state manager hold open office hours once a week, during which she gives a rundown of the week’s developments, trends, opportunities, and other topics. She noted that verbal communication is more effective than e-mails, which can get overlooked. Ms. Culp noted her team also has standing check-in calls across state and federal government affairs, grassroots, and communications teams. And Ms. Albizo pointed out that by virtue of her role and the small size of her team, she and they are in constant communication.

State and Federal Policy Tracking and Communications Tools. All three panelists use Fiscal Note, particularly for state-level work. They also count on their lobbyists and partners on the ground for intelligence gathering.

Managing Grassroots Advocacy and Communications. Ms. Sullivan’s team at EveryLife Foundation focuses on providing summaries of state issues, using a member portal to provide timely updates. Ms. Culp’s team focuses a lot on offline engagement and building their network to do calls and in-person visits. They focus less on e-advocacy because they are finding e-alerts do not work well anymore at the state level and are easier to do at the federal level because legislation moves more slowly. Ms. Albizo’s team uses Voter Voice when needed, but because the Immune Deficiency Foundation is so small, they usually focus their efforts only on certain states at a time.

Key Takeaways from Breakout Sessions

Participants divided into small, facilitated breakout groups to share their thoughts and experiences on building high-functioning federal and state government affairs structures. The following are key takeaways from those sessions.

• Leverage regional policy councils if your organization is small; this helps stretch your teams’ efforts further.
• Coalitions and campaigns work well for laws that get reauthorized every six
• Partnerships are valuable; they can be key to getting an issue in front of legislators, gathering information at the state level, sharing the workload, and getting your organization a seat at the table.
• It is important to be able to assess the appetite of your constituent community to get involved, what are the right issues on which to engage, and when to
• Always tell the story of your work and make people understand the WHY.