What’s on the Minds of the States?

Milbank State Leadership Network

Put a bunch of state leaders in a room, kick out the hangers-on, close the door, and ask them where they need help in health policy. What do they say? This is not a hypothetical question. The Milbank Memorial Fund did just that for three weeks in a row last month. And the responses were illuminating.

The occasion was the fall meetings of the Fund’s Reforming States Group (RSG), a group with a 20-year-old tradition of convening state health policy leaders—Republicans and Democrats, executive branch officials and legislators, leavened with a few international and metropolitan officials—in a collegial, confidential setting to share ideas, do some professional networking, and identify important issues in health policy.

This year, we gathered 95 people from 38 states in three meetings. We invited inter-branch, bipartisan delegations of senior directors and relevant committee heads from each of the states. These professionals understand that policy progress requires hard work across constituencies. RSG meetings are great opportunities to share thinking, build relationships across states, strengthen them within states, and bring ideas home.

As these folks focused on an agenda developed by their own leadership group, we listened. We wanted to hear what was on their minds. Where did they see a need for evidence and experience—collected, synthesized, and shared by the Fund—that would help them make the policy decisions that would improve the health of the populations they serve?

In each meeting, we listed what we heard, and then had the RSG members prioritize the issues. After the last meeting, 35 issues had been identified. We came away from the meetings with three prioritized lists and a very strong sense of what was going on in the minds of people who lead discussions on health policy in their jurisdictions. The list of priorities is summarized here. Without breaking confidences or interrupting an ongoing process, here are some observations so far.

The Issues Mentioned: The Affordable Care Act (ACA) Is Not about the Evidence

With the exception of sustainability plans for state-based exchanges, there was no instance in which participants were looking for more information or evidence about the insurance elements of the ACA. No webinars on Medicaid expansion or exchanges or rate review from the Fund, please. We have all the evidence we need, they seemed to be saying. These issues do not turn on more information, but on leadership and political will.

The General Priorities: So Many Issues, So Little Time

Three sets of lists and five prioritized items for each meeting resulted in 14 different issues identified—and only two duplicated priorities across the three meetings. There is a remarkable diversity of concerns among the states. Some states wanted to address a lack of providers and the need for policies regarding telemedicine, while others wanted to know what to do when their providers consolidate. Some were focused internally on management and budget issues, while others were looking at broad, creative Medicaid reallocations to accomplish great ambitions.

While this diversity of concerns might reflect the dynamics of the particular meetings, it also speaks to local realities. The variety of geographies, economies, and demographics among the states—and their resulting cultural values—has been a political reality since the founding of the country and a constant challenge to policymaking. One approach does not suit all.

The Top Priorities

So what bubbles to the top? With the exception of a few narrowly focused issues—integrating health services for newly released prisoners and prescription management programs—I was struck by the broadness of the top two concerns from each meeting: reprogramming Medicaid for social services, financing prevention, using data for population health measurement, and getting ready for the impact of aging boomers. The policymakers are thinking big and long term, and responding to the preponderance of evidence that we spend our money on medical care when the impact is upstream, in social issues and determinants.

These are not trendy issues—they are the persistent ones that will be around long after we have figured out how to provide health insurance to people. As leaders, RSG members are drawn to these sticky problems, as they look for good evidence and the “policy window” to make incremental progress on them.

In the coming months, the Fund and RSG leadership will keep examining these priorities, focusing them, prioritizing them further, and figuring out—in keeping with the Fund’s mission—where and how to connect RSG members and other leaders to the best evidence and experience to improve population health in their jurisdictions. It is a privilege to support them in this work.