Takeaways from NASHP: What’s Next in the States in 2020

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Avalere’s state policy team recently attended the National Academy for State Health Policy’s (NASHP) Annual Conference for 3 days of interactive state health policy discussions and the facilitation of a roundtable on the direction of telehealth in the states.
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As the largest state health policy conference in the country, NASHP draws a diverse crowd of state policymakers, regulators, and other stakeholders together to discuss priority policy issues in the states.

Here are the 4 main takeaways from the conference:

  1. Drug importation from Canada continues to capture states’ interest. As of mid-September, 4 states have enacted laws regarding the design and implementation of drug importation programs from Canada. Federal law allows for approval of a state’s importation program—though there is currently no defined certification process—if it satisfies 2 fundamental requirements: (1) the program must not pose any additional public health risks; and (2) it must result in a significant savings for consumers. In 2018, VT became the first state to pass an importation law. In 2019, 3 states (CO, FL, and ME) passed similar importation laws, and an additional 15 state legislatures considered or are considering similar legislation. On July 31, HHS and FDA released a plan outlining 2 potential pathways for drug importation. Under the first pathway, manufacturers could import their own products to provide lower-cost options in the US. The second pathway would allow states, wholesalers, and pharmacists to propose demonstrations to import drugs from Canada, under a new framework that HHS will describe in forthcoming rule-making. It remains unclear whether the 4 states that have passed laws will design programs that align with HHS’ forthcoming framework, and it is likely that this will be an active area for states in 2020.
Drug Import Legislation Map

Map credit: Avalere State Reform 360®

  1. Patient out-of-pocket spending on health insurance has been climbing. Many states are looking for ways to increase coverage affordability and lower patient out-of-pocket costs through implementation of public options or reference pricing. Additionally, as state spending on high-cost drugs—such as those used to treat cancer patients—has risen, states have been exploring different approaches to reduce budgetary pressures. In past years, MT implemented Medicare reference-based pricing on state employee plans, which the MT Health Care and Benefit Design Office has estimated will save the state $13 million. NC is working on a strategy to implement a similar plan but has yet to secure broader stakeholder support in the state. Other states have explored reinsurance programs (e.g., CO) and public options (e.g., WA) to increase coverage and reduce long-term spending. Looking ahead to the 2020 legislative sessions, states are likely to keep pursuing novel ways to reduce out-of-pocket spending, increase coverage access, and reduce budgetary pressures.
  2. Medicaid programs will continue to seek access to waivers for substance-use disorders and mental health conditions. Access to mental health disorder treatment has increasingly been a focus of Medicaid Section 1115 Innovation waivers. As the opioid epidemic remains an area of concern for many states, particularly in the Midwest, South, and Northeast, states are seeking waivers that may help to provide easier access to care for underserved populations, especially those needing treatment for substance use disorder (SUD), polysubstance use, and mental health conditions. CMS continues to support these efforts to respond to the opioid crisis by allowing the use of federal funds for SUD and opioid use disorder treatment. Additionally, states are expanding behavioral health services and disability services to broader populations. In the 2020 legislative sessions, many states may view section 1115 SUD waivers as an innovative option to leverage Medicaid funding to alleviate the costs of drug addiction treatment.
  3. Surprise medical billing has been a priority topic for state legislative and regulatory action, also capturing Congressional attention. As of September 16, 25 states have enacted either partial or comprehensive laws that would protect against surprise medical billing for unexpected charges that patients receive for care from providers who are out-of-network. Legislative efforts to date have targeted commercial health insurance plans and do not provide protections for enrollees in self-insured employer-sponsored plans. Both state legislators and US Congress have shown interest in developing legislation that would apply these laws to provide greater patient protection from unexpected, costly medical bills. In the 2020 legislative sessions, bills to further regulate surprise medical bills and expand to larger insured populations are expected.

There is a strong appetite among state policymakers to continue to tackle complex healthcare needs in the year to come. As the 2020 sessions begin to take shape, drug pricing, patient out-of-pocket costs, and Medicaid waivers will be just a few of the diverse topics that policymakers will seek to address.

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