State Update

Reports of Interest - September 2014

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The National Network for Oral Health Access issued a paper presenting the results of a national survey of health centers that NNOHA conducted in June 2013 to obtain information about school-based oral health programs located in school-based health centers (SBHCs) and operated by health centers.

National Governors Association Releases an Issue Brief on Prescription Drug Abuse

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According to the National Governors Association (NGA), prescription drug abuse is the fastest growing drug problem in the United States and the second most common type of drug abuse (following marijuana use among 12- to 17-year-olds). Prescription drugs account for nearly 60% of all deaths from drug overdose. Pain relievers such as oxycodone, hydrocodone and methadone are involved in three of every four prescription drug overdose fatalities.   In 2012, the NGA established the Prescription Drug Abuse Project led by NGA Vice Chair Gov. John Hickenlooper (D-CO) and Gov. Robert Bentley (R-AL). Throughout the yearlong initiative, seven states—Alabama, Arkansas, Colorado, Kentucky, New Mexico, Oregon and Virginia—worked to develop comprehensive, coordinated plans to combat the public health and safety crisis. During the 2014 Winter Meeting, NGA released an issue brief detailing lessons learned from the policy academy. The issue brief details specific policy changes made in the seven states to reduce prescription drug abuse. In addition, the NGA highlighted lessons learned from the policy academy that can inform other states’ efforts to combat the abuse such as: Changing prescribing behavior; Making disposal options convenient and cost-effective; Tackling the underuse of prescription drug monitoring programs; and Ensuring that data, metrics and evaluation are driving policy and practice. The NGA staff will continue to work with teams of senior-level policymakers including governors’ health and criminal justice advisors, state health officials, attorneys general, state chief information officers, legislators, physicians and allied health professional groups to examine a variety of issues related to prescription drug abuse, including: Building and governing a prescription drug monitoring program and implementing privacy safeguards; Assessing legislative, regulatory and information exchange barriers; Developing a coordinated state response across agencies; Coordinating across states and within regions; and Coordinating education, tracking and monitoring, proper medication disposal and enforcement efforts.

Reports of Interest March 2014

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The National Governors Association (NGA), Health Care Sustainability Task Force released a report providing several recommendations which the federal government can adopt to reduce barriers to innovation and further support state health care initiatives. Co-chaired by Gov. Bill Haslam (R-TN) and Gov. John Kitzhaber (D-OR), the Task Force is comprised of 10 governors from the following states: Alabama, Arkansas, California, New Mexico, New York, Oregon, South Dakota, Tennessee, Utah and Vermont. In addition, the immediate past leadership of the NGA Health and Human Services Committee, governors from Nevada and Maryland, serve on the Task Force as ex-officio members.The Task Force met regularly from late May through November 2013. At the outset, the Task Force identified principles that governors believe should serve as the foundation for state-federal efforts. These principles provided a framework for the development of recommendations in four key areas: federal support of state health care innovation; Medicare-Medicaid enrollees (dual eligibles); long-term services and supports; and payment and delivery reform. Within each of these four key areas, the Task Force made several recommendations for the federal government to adopt. The following is a brief highlight of several of the recommendations included in the report: The Centers for Medicare and Medicaid Services (CMS) and other federal partners should standardize and streamline the process of reviewing and approving state proposals to innovate in Medicaid/CHIP, including waivers and state plan amendments. CMS should establish a work group with states to conduct a comprehensive review of existing options to serve dual eligibles and identify policy changes that would: (1) allow states to serve broader populations through these programs, and (2) support states’ ability to finance these programs through greater flexibility and shared savings. Congress should enact legislation giving states the option to pursue and test flexible payment and delivery transformation initiatives, including models that are not explicitly authorized in statute, under a sustainable budget arrangement. Congress should establish clear parameters for states to undertake such initiatives and allow states to realize a return on their investment by sharing in federal savings that accrue as a result of proven state health care transformation. The Wisconsin Center for the Advancement of Postsecondary Education (WISCAPE) released an issue brief calling for states to collect more data from for-profit postsecondary institutions, so as to better assess the causes of these institutions’ disproportionately high student loan default rates. The Minnesota Board of Dentistry (BOD) issued a report on the preliminary impact of dental therapists in Minnesota. The 2009 Minnesota Legislature directed the BOD, in consultation with the Minnesota Department of Health (MDH) and the Department of Human Services (DHS), to evaluate dental therapists’ impact on the delivery of and access to dental services. The BOD surveyed 15 clinics employing dental therapists from August 2012 through December 2013. Specifically, the report found that since licensing commenced in 2011, four complaints have been filed against dental therapists. Two have been resolved without BOD action and two are pending. None have been directly related to patient safety issues. Also the report found that 84% of patients served by dental therapists were enrolled in public health insurance programs. Preliminary findings suggest that dental therapists may reduce emergency room (ER) use by expanding capacity at dental clinics serving vulnerable populations. Surveyed clinics also reported additional impacts of dental therapists, including personnel cost savings, increased dental team productivity and improved patient satisfaction.

Reports of Interest February 2014

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The National Governor’s Association released an issue brief titled The Role of Dental Hygienists in Providing Access to Oral Health Care. The brief examines the barriers to access of oral health care many low-income Americans face and how states are looking toward alternative provider models to address the issue. 

Reports of Interest January 2014

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The Institute for College Access & Success issued a report finding that seven in ten college seniors who graduated in 2012 had student loan debt, with an average of $29,400 for those with loans. The national share of seniors graduating with loans rose in recent years, from 68% in 2008 to 71% in 2012. Their debt at graduation increased by an average of 6% per year. The Kaiser Commission on Medicaid and the Uninsured released a report finding that in the 25 states not expanding Medicaid, 5 million Americans will fall into a “coverage gap,” in which they neither meet Medicaid eligibility guidelines for their state nor qualify for subsidies to purchase coverage on a health insurance marketplace. Beginning January 2014, the Affordable Care Act (ACA) will expand Medicaid to cover adults younger than 65 with income at or below 133% of the federal poverty level (FPL), or about $16,000 for an individual. To date, 25 states have declined or not yet decided to join the expansion, which the U.S. Supreme Court made optional for states in its 2012 decision on the ACA. Low-income people in these states will be able to obtain federal subsidies, known as “premium tax credits,” to purchase coverage on a marketplace, or exchange, if they have income between 100% and 400% of the FPL. However, the nearly 5 million people in the coverage gap have income that places them above their state's Medicaid eligibility level but below the level at which they may obtain premium tax credits to purchase coverage on an exchange. This group also includes people in non-expansion states who are ineligible for Medicaid because of their categorical status (single adult without dependent child).

Reports of Interest December 2013

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The White House issued a United States map which identifies the states that have currently chosen not to expand Medicaid under the Affordable Care Act and provides data on the number of Americans in those states that will be impacted. According to the map nearly 5.4 million Americans will remain uninsured in states that do not expand their Medicaid program. The Robert Wood Johnson Foundation issued a report analyzing premiums and cost sharing in the new health insurance marketplaces and found that almost half of those predicted to buy insurance on the exchange will be eligible for tax credits that would reduce their premiums. The Urban Institute and the Robert Wood Johnson Foundation released a report which explores several strategies states could implement, beyond the federal requirements included in the Affordable Care Act, to protect consumers from health insurance premium increases caused by rate shock. The report uses policy decisions in 11 states—Alabama, Colorado, Illinois, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island, and Virginia—to illustrate the mixed approaches states are using to mitigate rate shock. According to the report, states are implementing the following: Colorado, Minnesota and Alabama have begun transitioning people with pre-existing conditions out of high-risk pools into plans with younger, healthier people. Maryland, New York and Oregon are protecting against insurers undercutting the health insurance exchanges by “locking them out” in subsequent years if they don’t participate in year one—as well as limiting the sale of catastrophic plans. Maryland, New York, Oregon and Colorado also standardized broker compensation inside and outside the exchange to prevent customers from being steered away from one market toward another.

November 2013 Reports of Interest

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The U.S. Government Accountability Office issued a report that describes: (1) trends in coverage for, and use of, dental services; (2) trends in payments by individuals and other payers for dental services; and (3) the extent to which dental fees vary between and within selected communities across the nation. According to the report, the percentage of the population with private dental coverage decreased from 53% to 50%. Dental coverage through Medicaid or the State Children’s Health Insurance Program (CHIP), which was established in 1997, rose from 9% to 13%. The increase was due primarily to an increase in the number of children covered by these federal-state health programs with mandated pediatric dental coverage. In addition, the report found that average annual dental payments—the total amount paid out-of-pocket by individuals and by other payers—increased 26%, inflation-adjusted, from $520 in 1996 to $653 in 2010. Average annual out-of-pocket payments increased 21% (from $242 to $294) for individuals with private insurance and 32% (from $392 to $518) for individuals with no dental coverage. The College Board released a series of reports on the cost of higher education. The Trends in Higher Education publications included the following reports that are of interest to academic dentistry: Trends in College Pricing (report)     This report provides information on the prices charged by colleges and universities in 2013–14, how prices have changed over time, and how they vary within and across types     of institutions, states and regions. The report also provides information on the net prices that students and families actually pay after taking financial aid into consideration. Trends in Student Aid (report)     According to this report, the sharp increases in federal grant aid and in student borrowing accompanying the financial crisis, during the Great Recession, have not been     repeated. The report finds that while the federal government continues to play a large and increased role in funding students, spending on both federal grants and federal loans     decreased in 2012–13. The Henry J. Kaiser Family Foundation released a report finding that approximately 5.2 million low-income, uninsured adults will fall into the “coverage gap,” created by an estimated 26 states choosing not to expand Medicaid under the Affordable Care Act. Specifically, in states that do not expand Medicaid, low-income uninsured adults with incomes above Medicaid eligibility levels but below the poverty level may fall into a “coverage gap” from earning too much to qualify for Medicaid but not enough to qualify for Health Insurance Marketplace premium tax credits. The report notes that most of these people have very limited coverage options and are likely to remain uninsured. This brief describes the coverage gap and provides state-by-state estimates of the population that falls into this situation. The Geiger Gibson Program in Community Health Policy and the RCHN Community Health Foundation issued a report, which finds that health centers in states expanding their Medicaid program under the Affordable Care Act will potentially see 2.8 million patients gain coverage and, as a result, will generate a potential revenue increase of over $2 billion     

October 2013 Reports of Interest

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The Robert Wood Johnson Foundation (RWJF) released three oral health reports. Researchers commissioned by the RWJF examined 25 programs that addressed barriers to preventive oral health services with solutions in non-traditional, community and mobile settings. The reports below culminate a two-year collaborative effort led by a team from RWJF and consultant ICF International. Dental Professionals in Non-Dental Settings (report) The report evaluates nine programs that seek to increase access to preventive oral health care in non-dental settings, such as senior centers, schools and Head Start sites. Each program works to expand the dental workforce by training new types of providers. Providing Preventive Oral Health Care for Infants and Young Children in Women, Infants, and Children (WIC), Early Head Start, and Primary Care Settings (report) The report evaluates seven oral health programs that provide preventive oral health care to young children (infants, toddlers, and children up to 5 years old) in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start (EHS), and primary care settings. All of the programs strive to increase access to preventive oral health care by integrating dental services into primary care settings, WIC clinics, or EHS centers. Innovations that Address Socioeconomic, Cultural, and Geographic Barriers to Preventive Oral Health Care (report) The report evaluates nine programs seeking to increase the number of children from low-income families who receive preventive oral health care, and to encourage families and communities to prioritize oral health. Two of the programs evaluated incentives for providers to see more Medicaid-eligible clients; seven established new clinics and mobile units, some staffed by dental hygienists; and eight programs identified Medicaid-eligible children through Head Start and social service agencies. The University of North Carolina at Chapel Hill released a report on 17 states(3) that could serve as policy laboratories to provide federal and state policymakers with a range of innovative ideas about how to reform graduate medical education (GME) policy, governance and finance. While the study revealed numerous instances of successful attempts to reform GME, no single state employed innovative approaches in all four study aims.(4) However, the report offered recommendations to state policymakers as they continue to address GME funding. Recommendations included the following: states should create a GME advisory entity that promotes discussion, coordination and education about GME; all payer, third-party payer, Medicaid and state appropriations for GME need to be carefully considered and designed to be responsive to the state’s population health needs; and new GME funding should be tied to performance metrics and require monitoring about how funds are spent. Health Affairs and the Robert Wood Johnson Foundation released an issue brief providing details on the new excise tax on high-cost health plans proposed to both slow the rate of growth of health costs and finance the expansion of health coverage under the Affordable Care Act. The provision is often called the "Cadillac" tax because it targets so-called Cadillac health plans that provide employees the most generous level of health benefits. These high-end health plans' premiums are mostly paid for by employers. In addition, the plans have low, if any, deductibles and little cost sharing for employees. The U.S. Department of Health and Human Services, Office of Inspector General issued a report finding that the 12 states that volunteered to work with the Centers for Medicare and Medicaid Services had made little progress in implementing the Transformed Medicaid Statistical Information System (T-MSIS). T-MSIS is designed to be a detailed national database of Medicaid and Children’s Health Insurance Program information to cover a broad range of user needs, including program integrity. The Kaiser Commission on Medicaid and the Uninsured issued a report surveying the Medicaid budgets for all 50 states and the District of Columbia. The report found that improvements in the economy resulted in modest growth in Medicaid spending and enrollment in FY13. States moving forward with the Medicaid expansion are expected to see higher enrollment and total spending growth driven by increases in coverage and federal funds. Additionally, according to the report, the implementation of the Affordable Care Act (ACA) will result in major changes to Medicaid eligibility and enrollment for all states, whether they are implementing the ACA Medicaid expansion or not.   Trust for America’s Health released a report finding that 28 states and the District of Columbia scored six or less out of 10 possible indicators of promising strategies to help curb prescription drug abuse. Two states—New Mexico and Vermont—achieved the highest score, receiving all 10 possible indicators, while South Dakota scored the lowest with only two. According to the report, prescription drug related deaths now outnumber those from heroin and cocaine combined, and drug overdose deaths exceed motor vehicle-related deaths in 29 states and the District of Columbia. To view state-by-state prescription drug overdose death rates and learn how your state scores on the 10 key steps to curb abuse, click here.     (3) The 17 states studied include: California, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New York, North Carolina, Tennessee, Texas, Utah, Vermont, and WWAMI states (which include Washington, Wyoming, Alaska, Montana, and Idaho). The latter 4 states have an agreement whereby they send students to the University of Washington, which serves as a public medical school for all 5 states. According to the report, researchers did not interview any experts from Alaska or Wyoming for the study, but did interview WWAMI experts who were familiar with GME policies and programs in all 5 states. (4) The objectives of this study were to examine the extent to which states have, or plan to: 1) use health workforce data to assess residency training needs; 2) implement novel GME financing initiatives, including all payer systems; 3) create governance structures to allocate GME positions between specialties, geographies and training sites; and 4) establish policies or measures to encourage accountability of public funds invested in GME.

September 2013 Reports of Interest

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The Center for American Progress issued a report finding that some student loans should be dischargeable in bankruptcy. According to the report, the discharge of student-loan debt through a bankruptcy proceeding is extremely rare. Unlike most other debts, student loans may follow borrowers to the grave and result in the garnishing of wages and the seizure of Social Security checks. Meanwhile, most other financial obligations remain dischargeable, including credit card debt and, in some cases, gambling obligations. The report contends that students who do not meet the two-prong standard—have borrower-friendly terms and some evidence that graduates, based on their employability, are likely going to be able to repay these loans—would be eligible for discharge in bankruptcy just as credit cards are. The National Center for Education Statistics released the results of its national postsecondary student aid study. The survey includes about 95,000 undergraduate and 16,000 graduate students attending 1,500 postsecondary institutions in the 50 states and the District of Columbia. The report describes the percentages of students receiving various types of financial aid and the average amounts received by type of institution attended, attendance pattern, dependency status and income level. Specifically, the report finds that 70% of graduate students received some type of financial aid. Twelve percent of graduate students received assistantships and 45% took out student loans, including 43% who took out federal Direct Loans and 10% who took out federal Direct PLUS Loans for graduate students. The Association of State and Territorial Dental Directors released a policy statement encouraging integration of oral health in health education curricula in schools. The Henry J. Kaiser Family Foundation released an Affordable Care Act (ACA) interactive subsidy calculator. The tool illustrates health insurance premiums and subsidies for consumers purchasing insurance on their own in the new health insurance marketplaces created by the ACA. Beginning October 1, 2013, people under age 65, who are not eligible for coverage through their employer, Medicaid or Medicare, can apply for tax credit subsidies available through state-based exchanges. Additionally, states have the option to expand their Medicaid programs to cover all people making up to 133% of the federal poverty level. In states that opt-out of expanding Medicaid, some people making below this amount will still be eligible for Medicaid, some will be eligible for subsidized coverage through health insurance marketplaces, and others will not be eligible for subsidies. With this calculator, you can enter different income levels, ages and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. The U.S. Department of Health and Human Services has created an interactive U.S. map which allows users to obtain information regarding how the Affordable Care Act is impacting residents in their state.

August 2013 Reports of Interest

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The Association of State and Territorial Dental Directors issued a summary report providing a synopsis of state dental public health programs using data and information from FY 2011–12. The report provides information regarding the number of community-based dental clinics for low-income residents; local health departments with restorative dental services; local health departments with education and preventative oral health programs; and mobile dental clinics with preventative dental services. In addition, the report provides dental workforce data including the percent of counties in a state that do not have a dentist and that do not have a dentist enrolled as a Medicaid provider. The American College of Obstetricians and Gynecologists has issued an opinion recommending that obstetricians and gynecologists perform routine oral health assessments at the first prenatal visit and encourage their patients to see a dentist during pregnancy.   The North Carolina Institute of Medicine, a quasi-state agency created to provide nonpartisan information to the public, issued a report making recommendations to achieve the following two goals: increase the percentage of children enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) who receive preventive dental services and dental sealants, and increase the utilization of preventive oral health services among children enrolled in Medicaid and CHIP by any appropriate health professional. Some of the recommendations include reducing barriers that discourage dentists from participating in Medicaid and CHIP, increasing reimbursement for dental sealants, and creating systems for greater collaboration between primary care providers and dental professionals. The Robert Wood Johnson Foundation and Health Affairs published a policy brief which explains how the new premium tax credits under the Affordable Care Act will function, who is eligible to receive the tax credits, and what state and federal government agencies, as well as outside groups, are doing to educate the public.