What a Difference a Day Makes…

Tomorrow it will all be over, this long, costly, bitter, and divisive election will be behind us and we will know who America has chosen as our President, who has been elected to Congress, and a host of other important electoral outcomes. While this election has too often highlighted the differences within our country, a recent news story caught my attention – a bakery in North Carolina is reviving the tradition of baking election cakes. It seems our forebears celebrated each election with community events and rum soaked cakes – where all sides came together to celebrate democracy.
In the spirit of that history, let’s look for the icing on the cake. Perhaps this election will be the tipping point, bringing us all out of our corners and together to solve problems. Maybe this bitterness will give way to resolution that will usher in an era when Congress and the new Administration can work together to solve the challenges we face as a nation. But no matter what happens in Washington, states remain pragmatists, working to balance budgets and address priorities.
In health care, states have made extraordinary progress with support from the federal government. CMS has operationalized the Office on Medicare and Medicaid Coordination and the Center for Medicare and Medicaid Innovation is investing in multiple demonstrations designed to improve how care is delivered and financed.
While the rhetoric around Obamacare has been heated and the policy debates real and intense, progress is inescapable, as is the fact that it is largely fueled by the Affordable Care Act (ACA). More people have health coverage than ever before. There is general support for the elimination of preexisting conditions, for allowing kids to stay on parents’ health plans until age 26; for the need to address costs and particularly pharmaceutical costs. And thanks to ACA investments, states are actively engaged in creative efforts to restructure how care is delivered and paid for to improve health and lower the cost trajectory.
Seventeen states administer state-based insurance exchanges or do so in partnership with the federal government. All 50 states have streamlined and simplified Medicaid eligibility and enrollment, and are working with the exchanges. For the first time, state demonstrations are coordinating Medicare and Medicaid to better serve elders and persons with disabilities.
The debates around Medicaid expansion and the opposition to the ACA mask bipartisan progress. Some “red states” have established State-based Marketplaces and expanded Medicaid using models that address state differences. Ten states – both “red and blue”- have implemented ACA-funded demonstrations testing whether financial incentives will motivate Medicaid beneficiaries to seek and initiate activities that improve health. States have created new community-based approaches to support health care delivery and payment models that address social determinants of health and one state will soon test an all payer statewide ACO. Thirty-six states are implementing Systems Innovation Model (SIM) federal demonstrations and 10 states, again both “red and blue”, have launched Delivery System Reform Initiative Programs (DSRIP)-among many other Medicaid waivers and similar initiatives. The states are alive with demonstrations and eager to focus these efforts into a strategic, on-going approaches to reform. Increasingly states realize that moving our health care system from paying for volume to value requires alignment among payers and this will require new partnerships with the federal government as well as new federal approaches to cross-agency collaboration. Now that Medicaid covers more people than Medicare, new approaches to policymaking and collaboration can enhance the purchasing power of those two important programs.
Regardless of the outcome of this election, there is considerable work underway in the states to inform national policy. NASHP convened a Summit of state leaders who have thought hard about state roles and a new Administration. We will release a paper soon informed by those discussions that lays out ideas to continue and expand state initiatives. States have long served as laboratories of innovation – major federal legislation like the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the ACA were enacted only after states had experimented with children’s health care; insurance regulation, and insurance exchanges. Of course there are staggering challenges before us; the results of these state demonstrations won’t all be positive and there are many, many barriers to overcome to assure all have access to quality, affordable health care and better health. But on this Election Day, let’s reflect and think back to the early colonies and their experiment in federalism and democracy. An election cake and a celebration of this day may no longer have a place in our hurried, modern world but the idea of coming together – building on the federal-state collaboration underway to improve health and lower costs- still has great promise.