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The Milbank Memorial Fund is an endowed operating foundation that aims to improve population health by connecting leaders and decision makers with the best available evidence and experience. It does this work by:
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
October 2, 2020
Reforming States Group Sustainable Health Care Costs State Health Policy Leadership
David K. Jones Read Bio
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Health care costs are one of the most pressing policy issues of our time and are perhaps even more important in the coronavirus era, when state and many family budgets are deeply stretched. Yet conversations about health care costs are often unproductive, as people talk past one another and use the same words to mean different things. For instance, some use “costs” to mean costs borne by individuals, such as premiums and deductibles, whereas others use “costs” to represent costs to providers, insurers, hospitals, or the government. Developing a shared understanding of what we mean when we talk about health care costs—and which issues need to be solved—are the critical next steps toward developing consensus on solutions.
We surveyed state legislators across the country and conducted case-study interviews in four states (Colorado, Michigan, South Carolina, and Vermont) to understand their health policy priorities, how they think about health care costs, and how to have a more productive conversation about solutions. Our research suggests that there is more opportunity for bipartisan agreement than many realize.
This report highlights six key findings. First, in many states there are effectively three parties, not two. Although many legislators fit best into groups that are predominantly Democratic or predominantly Republican, about a third fit better in a third group comprising moderates from each party. It’s noteworthy that Republicans in this third group say that reducing the role of government is a low priority. A coalition of such moderates is bridging divides on health care costs even in states with intense partisan splits, like Michigan.
What this tells us is that the answer to rising health care costs may well lie in initiating state-level conversations among moderates and reframing the way we talk about health care costs, rather than in overturning deeply held ideological beliefs.
Second, which health-care-cost priorities legislators are focused on—for example, high premiums for individuals or the budget impact of rising costs on states—is not particularly partisan. This finding of a nonfinding is at first glance frustrating but might actually be good news. It suggests that people’s understanding of what they mean by “health care costs” is not hard-wired or ideological. As a case in point, our third finding is that all legislators placed a high priority on pharmaceutical costs.
Fourth, legislators still bring a partisan lens to the conversation about solving health care costs even if they do not think of the cost drivers in partisan terms. Legislators in the predominantly Republican group tended toward solutions focused on the impact of high costs on individuals, whereas Democrats and moderates from each party tended to support solutions trying to understand and mitigate the systemic drivers for those high costs.
Fifth, the most productive conversations about solving health care costs were most likely to occur in states with pockets of expertise. A pocket of expertise is a small number of people who have spent considerable time thinking about health care costs and have developed channels of information sharing with each other. These policymakers almost universally thought about solving health care costs in systemic terms and were able to move the conversation in their states in this direction. Specific examples from these states illuminate our sixth finding, which is that people in these pockets of expertise are framing proposals about health care costs to appeal to legislators focused on both individual and systemic drivers of cost by emphasizing both affordability and transparency.
Our survey did not uncover deeply entrenched partisan splits on the issue of health care costs, and there was a commitment on all sides to tackle the issue. What this tells us is that the answer to rising health care costs may well lie in initiating state-level conversations among moderates and reframing the way we talk about health care costs, rather than in overturning deeply held ideological beliefs. In sum, there is a way to move forward.
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