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Short Analysis
July 2019

Health and Health Care in 2019 Legislative Sessions: States Step Up on Public Options, Coverage, Drug Pricing, and More

State lawmakers focused on health care coverage as well as prescription drug and other health costs in a year that also saw Medicaid programs and reproductive health threatened by state and federal policymakers. Families USA’s annual review of state legislative activity found bold new ideas on public options, coverage enrollment, and consumer issues including drug pricing and surprise billing emerging in the statehouses. This review offers a look at the key issues in legislatures in 2019 and legislation that can serve as models for advocates and lawmakers in future legislative sessions.
 

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Public Options

New governors in 20 states helped set the agenda for a renewed emphasis on health care issues as sessions opened in 2019. The tone was set in State of the State addresses in Colorado, New Mexico, and Washington as governors expressed their intentions to expand health care coverage on the state level. Lawmakers followed with measures to put new structures in place to deliver health care. 
 
Washington — SB 5526 — Gov. Jay Inslee and Washington lawmakers took a step to address the affordability of private insurance for people who do not receive federal subsidies through a hybrid public option plan. The measure, dubbed “Cascade Care,” uses the state’s health benefit exchange to contract with private insurers and sets affordability criteria on certain Bronze-, Silver-, and Gold-level plans beginning in 2021.
 
Colorado — HB 19-1004 — Colorado legislators passed a measure calling for a report from state departments in 2020 on a public insurance option. 
 
New Mexico — SB 536 – Lawmakers funded an additional study of a Medicaid buy-in option. New Mexico’s Human Services Department will consider the administrative development of the buy-in plan in 2019.

Coverage

While the federal administration pushed against the Affordable Care Act, states built upon it to assure coverage was available on health insurance marketplaces, and action was taken to encourage state residents to sign up for coverage. States also took action to defend against attacks on comprehensive coverage coming from federal policymakers.
 
Maryland — HB 814 — Maryland greatly streamlined the process for the uninsured to receive coverage by passing the Maryland Easy Enrollment Health Insurance Program. Families USA worked with the Maryland Citizens’ Health Initiative on the first-in-thenation measure to let uninsured individuals check a box on their income tax return that sends information from their tax return to the exchange, which then uses it to determine eligibility and enroll them into Medicaid, CHIP, and exchange plans.  Allowing signups outside the standard open enrollment period, the new law could potentially help more than 100,000 uninsured Marylanders obtain coverage, including through Medicaid and low-cost exchange plans. 
 
California — AB-74 — In the governor’s budget, California passed critical affordability assistance for state residents who earn too much to qualify for Medicaid. Building upon the tax credits that the Affordable Care Act provides, the state will provide additional assistance so that state residents who earn up to 600% of the federal poverty level will now quality for financial assistance with coverage through the state’s marketplace. Additionally, residents earning between 200% and 400% of the federal poverty level will receive extra help on top of their current financial assistance, and no individual who earns less than 138% of the federal poverty level who qualifies for marketplace coverage will pay premiums. The additional affordability assistance is partially funded by a state-level individual mandate, which then is supplemented with state general funds for the next three years. Health Access California, the Western Center on Law & Poverty, and other organizations in the Care4All California campaign advocated for this critical consumer help.
 
New Jersey — A5499 — After adopting an individual mandate last year, New Jersey followed up with transitioning to a state-based marketplace (SBM) for health insurance. The legislation calls on the state’s Department of Banking and Insurance to set up the marketplace. The plan includes integration with Medicaid eligibility determinations. The New Jersey Policy Perspective touted the need for the state marketplace, indicating that it will allow the state to improve the enrollment experience, among other benefits. 
 
Pennsylvania — HB 3 — Like New Jersey, the Keystone State will also be inaugurating a state-based marketplace for health insurance and using savings to fund a reinsurance program through a Section 1332 waiver. The legislation had the support of the Pennsylvania Health Access Network, which cited the benefits of reduced premiums for health care coverage in the new state marketplace. 
 
New Mexico — HB 285 — The state took a strong stand against plans that don’t comply with the Affordable Care Act by giving the insurance commissioner wide authority to set standards for short-term and other noncompliant plans. HB 285 requires these plans to cover a wide range of benefits and meet medical loss ratio standards. It also builds upon earlier state regulations on these plans, including by reinforcing that short-term plans may not last longer than three months and are nonrenewable. Representatives from Health Action New Mexico advocated for this legislation. Connecticut (HB 5521), the District of Columbia (B22-1001), and Maine (LD 1; LD 1260) also enacted legislation to restrict short-term plans this year. On the other hand, some states, like Florida and Arizona, went in the other direction and actually expanded access to these concerning, noncompliant plans.

Medicaid

Not all states, however, embraced coverage expansion in 2019. In the wake of Medicaid expansion ballot wins in 2018, some states followed the entreaties of the Trump administration to restrict or cap eligibility. The proposals included block grant funding for Medicaid, an unprecedented plan that would limit states’ funding and ability to deliver health care to vulnerable populations. Meanwhile, a court decision on Medicaid work requirements stalled proposals or stopped other states from passing such laws.
 
Utah — SB 96 — State lawmakers repealed and replaced a ballot initiative measure that expanded Medicaid under the Affordable Care Act. The replacement bill included a “bridge plan” or a partial expansion of Medicaid with a request for a waiver that would include a per capita cap on the program and cap on enrollment. The Utah Health Policy Project called the replacement proposal a “Broken Bridge to Medicaid Expansion.” The waiver requests are unprecedented and could have a catastrophic effect on the state budget and future Medicaid funding. The waiver is expected to be submitted to federal officials this summer. 
 
Georgia — SB 106 — While Georgia has not expanded Medicaid, legislators approved a proposal to seek a partial expansion under a federal waiver. The design of the waiver is undefined under the legislation. The details of the waiver will be determined from proposals by Deloitte, a global provider of consulting and other services, with plans for the state to submit a waiver by the end of the year. Georgians for a Healthy Future plans to engage in the waiver discussions and elevate consumer comments about the future proposals. 
 
Tennessee — HB 1280 — The Volunteer State is also looking for a Medicaid block grant waiver, but without the benefit of any type of Medicaid expansion. The legislation, which Gov. Bill Lee signed on May 24, was opposed by the Tennessee Health Care Campaign in part because it would pit health care coverage for children against other state priorities. The waiver proposal is expected to be submitted to the Centers for Medicare & Medicaid Service by late November. The Legislature will have final approval before any waiver takes effect.
 
West Virginia — HB 3136 — The threat of future lawsuits stalled a work requirement bill on the House floor at the end of the legislative session. Lawmakers in West Virginia, Iowa, and Wyoming dropped work requirement legislation after U.S. District Court Judge James Boasberg ruled against similar restrictions in Arkansas and Kentucky. West Virginians Together for Medicaid raised concerns about the legality of the proposal in the wake of the initial Boasberg ruling.

Health Equity

California — SB 104 — Gov. Gavin Newsom signed legislation to make California the first state to provide health care coverage to young adults regardless of their immigration status. The measure was part of a health budget package. The MediCal coverage expansion was among the provisions sought by the California Immigrant Policy Center, Health Access California, and other partners in the #Health4All campaign.

Drug Pricing

While Congress grapples with proposals to address the underlying problems that lead to high prescription drug prices, state lawmakers have been exploring options to provide more immediate relief to consumers and put pressure on drugmakers. Some states passed efforts to improve transparency in drug pricing and to leverage state purchasing power to reduce costs. Others advanced stopgap measures, including importation laws and lifting gag rules on pharmacists.
 
Maryland — SB 759 — Lawmakers in Annapolis created the first-in-the-nation Prescription Drug Affordability Board to rein in the cost of drugs bought by state and local governments. The board will help reduce the costs for drugs the state and cities pay for employees and health care programs. Maryland Citizens’ Health Initiative, AARP Maryland, and many coalition partners advocated over many months to bring this bill across the finish line. 
 
Maine — LD 1162 — Maine passed a package of bills to address high drug prices, including a measure requiring pharmaceutical companies to justify price increases and provide more detail on the costs. The legislative package signed by Gov. Janet Mills also included a take on the Prescription Drug Affordability Board and drug importation law. The measures were supported by Maine’s Consumers for Affordable Health Care.
 
Texas — HB 2536 — Transparency legislation will shine a light on drug price increases in Texas as part of an effort to make drug manufacturers explain the increasing costs of medications. The measure is viewed as a first step in making prescriptions drugs more affordable and was supported by AARP and the Center for Public Policy Priorities
 
Alabama — SB 73 — Pharmacy benefit managers (PBMs) drew attention from lawmakers in several states for their practices limiting pharmacists from providing information to consumers about alternative medications, and pricing or selling consumers lower-cost, clinically appropriate alternatives. These “gag clauses” were a target of legislation passed in Alabama in 2019. According to the National Conference of State Legislatures, 33 states have passed laws prohibiting the gag clauses.
 
Florida — HB 19 — Drug importation bills, like the measure passed in Florida, offer another potential way to make a more affordable option available for consumers. Like bills in Vermont and Colorado, the Florida legislation authorizes state agencies to seek the approval of the federal government to establish a program to import drugs from Canada or other countries. The proposal had the support of AARP in Florida

Oral Health

Oral health coverage is often limited for adults who rely on Medicaid or Medicare for their health insurance. Many states, however, are realizing the importance of oral health and improving dental coverage for adult Medicaid participants. This year, two states added dental coverage for all adults in their Medicaid programs, and many more states took incremental steps toward advancing oral health coverage and care for adults.

Delaware — SB 92 — The state will begin to offer preventive and restorative dental coverage to adult Medicaid recipients. This legislation is a huge win for our partners at Westside Family Healthcare and the Delaware Dental Hygienists’ Association in a state that previously offered absolutely no dental coverage for adults.
 
New Hampshire — HB 692 — The New Hampshire Oral Health Coalition lobbied for legislation that will require the Medicaid managed care program to provide dental benefits to Medicaid recipients. The bill is awaiting the governor’s signature.
 
Other states took smaller steps toward better oral health coverage for adults. 
  • Colorado will now offer oral health coverage to pregnant women enrolled in the state’s Children’s Health Insurance Program, and the state budget increased the annual limit for Medicaid adult dental services to $1,500. 
  • Kansas increased adult dental reimbursement rates in an effort to bring more providers into the program. 
  • Utah will offer dental coverage to senior Medicaid recipients through the University of Utah dental school program.
  • Virginia’s budget included an amendment directing the state to study costs incurred by Medicaid recipients related to emergency department visits for dental issues.

Surprise Billing

This was the year more lawmakers and insurance commissioners cracked down on surprise billing to protect consumers from facing charges for medical services unexpectedly provided out of network. This year’s legislative action brought the number of states with comprehensive surprise bill protections to 13, up from nine as of last year. Additionally, the state of Wyoming took a creative approach to addressing air ambulance network issues.

Colorado — HB 19-1174 — The Colorado Consumer Health Initiative won a multiyear fight for legislation to protect consumers from being hit with out-ofnetwork bills unexpectedly. Notably, this protection extends not only to providers and facilities but also to ground ambulances. The measure includes setting a reimbursement rate for out-of-network providers. It also requires more disclosure by insurers, providers, and hospitals about out-of-network services and charges. 
 
New Mexico — SB 337 — New Mexico joined its neighbor in passing legislation to both protect consumers from surprise medical bills and set a benchmark payment rate for reimbursement between insurers and out-of-network providers or facilities. The legislation was supported by the advocates at Health Action New Mexico
 
Texas — SB 1264 — The Center for Public Policy Priorities got a shout-out from Lone Star State lawmakers for raising awareness of the problems surprise medical bill cause consumers. The bill, which creates an arbitration process in cases of dispute between providers and insurers while leaving the consumer out of the process, won bipartisan support in both the House and Senate. It would protect consumers in emergencies and from out-of-network charges at an in-network hospital or laboratory.
 
Washington — HB 1065Northwest Health Law Advocates celebrated the signing of legislation to protect consumers from bills for out-of-network care during emergencies or when receiving care from certain providers at a facility within their insurance plan’s network. Like the Texas law, HB 1065 creates a process for arbitration between insurers and outof-network providers or facilities to resolve payment. The measure was spearheaded by state Insurance Commissioner Mike Kreidler.
 
Wyoming — HB0194 — Air ambulance services pose a financial shock for consumers, an especially great challenge in a rural state like the Equality State. Lawmakers chose a unique approach to address the air transport bills, which can run as high as $50,000. The Legislature asked the state Department of Health to seek a Medicaid waiver from federal officials to cover all air ambulance service. The state is taking comments on its proposal before submitting to the Centers for Medicare & Medicaid Services later this summer.