State Policy Updates

For updates on primary care-related actions by the administration and Congress, head to Federal Policy Updates.

For updates on efforts individual states are making to improve measurement and increase investment in primary care, visit the Primary Care Investment Efforts in States page


Delaware House passes bill that continues recent efforts to strengthen primary care system in the state

On June 29, the Delaware House passed a bill that continues recent efforts to strengthen the primary care system in the state by:

  1. Directing the Health Care Commission to monitor compliance with value-based care-delivery models and develop and monitor compliance with alternative payment methods that promote value-based care.
  2. Requiring rate-filings limit aggregate unit price growth for inpatient, outpatient, and other medical services to certain percentage increases over the next 4 years.
  3. Requiring an insurance carrier to spend a certain percentage of its total cost on primary care over the next 4 years.
  4. Requiring the Office of Value-Based Health Care Delivery to establish mandatory minimums for payment innovations, including alternative payment models, and evaluate annually whether primary care spending is increasing in compliance with the established mandatory minimums for payment innovations.

The senate passed the bill in May.

The legislation is modeled on Rhode Island's pathbreaking "affordability standards" that give the state insurance commissioner authority to promote investment in primary care through review of insurance plans' rates.

California Medicaid RFP

The California Department of Health Care Services solicited public comments on its draft request for proposal (RFP) for upcoming procurement of Medi-Cal (Medicaid) managed care plans. This is the first time California has conducted a statewide procurement, and it will cover 11 million Medi-Cal enrollees. The California Health Care Foundation publicized the opportunity for stakeholders to weigh in on ideas to improve access, equity and quality of care. Re-bidding state Medicaid managed care contracts is an important opportunity for primary care advocates to promote effective contracting practices (including reporting primary care spending), oversight and accountability processes, and appropriate alignment with other state payers and purchasers to advance comprehensive primary care.

Massachusetts task force calls for creation of statewide equity office and equity-focused review of response to COVID-19

A task force of state lawmakers and health experts called on the Legislature to create a statewide office and a Cabinet-level position focused on equity, and to immediately initiate an equity-focused review of the state’s response to COVID-19 in its final report released Thursday.

More States Pursuing Primary Care Investment Legislation

The Maine legislature is considering “An Act Regarding Targets for Health Plan Investments in Primary Care and Behavioral Health” (LD 1196 ). It will likely be carried over to next year with a stakeholder workgroup working on details over the summer and fall.

New York state lawmakers aim to establish primary care reform commission

News release from the Primary Care Development Corporation, a PCC Executive Member:

PCDC Supports Legislation to Strengthen Primary Care in New York

Primary care is undervalued and underfunded, despite evidence that it improves health outcomes and reduces costs

The Primary Care Development Corporation (PCDC) applauds the introduction of A.7230/S.6534, introduced by Sen. Gustavo Rivera, Chair of the Senate Health Committee, and Assembly Member Richard Gottfried, Chair of the Assembly Health Committee. The legislation would strengthen primary care through increased access to and affordability of care across the state. Lack of investment in primary care and prevention has led to rising healthcare costs and increasing rates of chronic illness, leaving New Yorkers vulnerable to threats like COVID-19. Investment in primary care is a crucial step in rebalancing the priorities of New York State’s health system and rebuilding our communities after COVID-19.

To date, at least ten states have acted to rebalance their healthcare spending through legislative, regulatory, or executive means. PCDC believes New York State must be next to act and is launching a statewide campaign to pass legislation to define, measure, and report on current primary care spending, and increase the proportion of the healthcare dollar that goes to primary care services across all payers.

“New York’s underserved communities have a pressing need for primary care, yet the providers and institutions that serve them have been unable to sufficiently sustain, expand, and improve services due to systemic inequities and drastic undervaluing of primary care services,” said Rivera. “The goal of this bill is to create a roadmap for New York State to adequately reinvest in primary care in an effort to make it more accessible and affordable, which is crucial to improving health outcomes across the State, especially in the communities that were hardest hit by the COVID-19 pandemic.”

“Expanding primary care is critical prevention and keeping people healthy and avoiding more dangerous and expensive complications down the line,” said Gottfried. “Our healthcare system — including in New York — seriously shortchanges primary care, which increases overall healthcare costs. And patients benefit when they have regular and consistent relationships with primary care practitioners. The primary care commission and spending targets will help New York correct the imbalance and build access to community-based primary care.”

Many of the neighborhoods with high rates of COVID-19 infections and poor primary care access are low-income neighborhoods with residents who are predominantly people of color and who experience high rates of chronic disease. Increased access to primary care is the first line of defense for these communities in the face of the ongoing COVID-19 pandemic as well as future disease threats.

Investment in primary care has vast economic benefits, including improved health outcomes, better health system efficiency, and increased health equity. Health systems that are oriented towards primary care simply function better. Yet, it is estimated that as little as 5% of U.S. healthcare spending goes toward primary care. New York currently spends more per capita on health care than the national average, but consistently ranks below many other states in key health indicators. This is indicative of a lack of access to and an underinvestment in primary care.

Primary care is often a patient’s first point of contact with the healthcare system, playing a critical role in preventing, identifying, and treating illnesses before they become chronic conditions. Research shows that an increase of just one primary care provider per 10,000 people can generate 5.5% fewer hospital visits, 11% fewer emergency department visits, and 7% fewer surgeries. In addition to improving health outcomes, upfront investment in primary care is cost-effective: findings from Oregon’s Patient-Centered Primary Care Home (PCPCH) Program showed that every $1 investment in primary care related to the program resulted in $13 in savings on other services.

Maura Harris, PCDC’s Policy and Advocacy Manager, noted in a recent story in Crain’s Health Pulse, “We need a mechanism to start understanding how much we’re investing in primary care and increase support for these services to keep people healthy.”

Louise Cohen, CEO of PCDC, emphasized the importance of the legislation stating, “Primary care is a cornerstone of vibrant, thriving communities and helps keep families healthy, children ready to learn, and adults able to pursue education and participate in the workforce. The passage of this bill is a crucial first step on the road to recovery from COVID-19, sustaining the primary care infrastructure, and improving the health of all New Yorkers.”

Public health advocates are calling for a stronger role for primary care to build back better a high-quality, affordable, and accessible healthcare system in New York. PCDC will be participating in a webinar discussion on Tuesday, May 18, 2021, at 12 p.m. ET with the New York State Health Foundation to highlight short- and long-term strategies related to public education and promotion; regulatory opportunities to bolster patient-centered care models; and rebalancing healthcare spending.

Utah Issues Its First Primary Care Spending Report

The Utah Department of Health issued a primary care spending report using the state’s All Payer Claims Database (APCD). The report uses the Maine Quality Forum’s definition of primary care to calculate the total amount of spending on primary health care services as a percentage of all healthcare expenditures. It found that primary care made up a combined 6.4% (narrow definition) and 8.5% (broad definition) of total expenditures in 2019. Primary care decreased from 2018 to 2019 for both Medicaid and commercial payers.

Oregon Value-based Payment Compact

Over 40 healthcare organizations—including several primary care providers—in Oregon signed a voluntary compact to advance the adoption of value-based payment (VBP) in the state. The groups committed to making a good-faith effort to “participate in and spread” VBPs, including moving from having 35% of all their payments be under advanced VBP models in 2021, to 70% by 2024. Read the principles that they signed on to. Their efforts corresponds with Oregon’s cost growth benchmark work that goes into effect this year.

Five States Join the Peterson-Milbank Program for Sustainable Health Care Costs

The Milbank Memorial Fund announced March 9, 2021, that Connecticut, Oregon, Nevada, New Jersey, and Washington have been selected to participate in the Peterson-Milbank Program for Sustainable Health Care Costs. With Peterson Center on Healthcare support, the Milbank Memorial Fund and Bailit Health will provide technical assistance to these five states as they set and implement healthcare cost growth targets. These targets are a first step toward making health care more affordable and transparent.

This program is just one Milbank Memorial Fund initiative that aims to empower and support state leaders in making health care more affordable for everyone.

“The Milbank Memorial Fund is excited to support these five leading states as they work with their stakeholders to set and implement a target and develop the data capacity necessary to identify and address the underlying causes of rising healthcare costs,” said Milbank Memorial Fund President Christopher F. Koller.

In the United States, healthcare costs have grown faster than the economy for decades. These rising costs are burdening states, employers, and families, as well as crowding out other critical priorities like education or housing. The COVID-19 pandemic has further stressed state, employer, and family budgets, and many states have a limited understanding of statewide healthcare spending and what is driving unsustainable increases.

“As we have seen across the nation and especially in our state’s ongoing battle with the pandemic, COVID-19 has not only devastated our economy, but it has turned gaps in coverage into chasms, especially for those who need it the most,” said Sara Cholhagian, executive director of Nevada’s Patient Protection Commission. “My hope is that this program will help our state address growth in healthcare spending across all populations.”

The Peterson-Milbank Program for Sustainable Health Care Costs supports state-led activities that engage cross-sector stakeholders, such as insurers, health providers, and employers, in designing, adopting, and implementing policies to measure total healthcare costs and set a statewide healthcare cost growth rate target so healthcare costs don’t outpace economic or income growth. The end goal is to stimulate data-driven systemwide action to address cost growth drivers and improve healthcare performance.

The approach is initially modeled on Massachusetts’s cost growth benchmark set in 2012. Since 2013, state spending growth has been, on average, lower than the benchmark and lower than the national rate of growth. In the commercial insurance sector, employers and individuals in Massachusetts spent about $7.2 billion less from 2013 to 2018 than they would have if the state’s spending growth had risen as fast as the national average.

To be selected, states had to demonstrate their leadership commitment — with a governor’s executive order or legislation establishing the target-setting process and resources to support it, as well as the appointment of a multi-stakeholder commission to oversee the work.

New England States Issue Regional PC Spend Report

A consortium of New England States, known as NESCSO, recently released a first-of-its-kind regional report on levels of primary care investment across six states. The analysis, based on administrative claims data for 7.2 million commercial, Medicaid and Medicare members across Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont, found that spending on primary care averaged 5.5% of overall healthcare costs. (Retail pharmacy is excluded from the denominator.) The data are largely in line with other studies of primary care spending levels, including PCC’s 2019 and 2020 evidence-based reports. Still, the NESCSO effort newly coordinates states to report on standard measures of primary care to allow for comparisons and regional benchmarking. It also attempts to capture non-fee-for-service spending, such as capitated payments and other investments, collected by states directly from payers.  
 

Delaware Sets Primary Care Investment Target

In December 2020, Delaware’s Office of Value-Based Health Care Delivery issued a new report on healthcare affordability standards that includes plans to “more than double primary care spending in the commercial fully insured market by 2025.” The office set a provisional target to increase investments in primary care by 1% to 1.5% of total cost of care each year until 2025, thus increasing primary care’s percentage of total spending from 5% in 2021 to between 9% and 11% by 2025. The report asserts that this will bring the state “to levels consistent with leading models of comprehensive primary care delivery nationally.”

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