Seven legislators with influence over Washington State health policy gathered last week to discuss their observations on health and fiscal policy since the previous legislative session ended, and how the pandemic in 2020 will impact the work of the Legislature in 2021.

The discussion took place between two panels – one featuring Republicans and the other featuring Democrats – at the 2020 Inland Northwest State of Reform Virtual Health Policy Conference.

The Republican Policy Leadership panel featured Reps. Joe Schmick, Jacquelin Maycumber, and Paul Harris. Sens. Karen Keiser, Annette Cleveland, Emily Randall, and Rep. Marcus Riccelli carried the torch for Democrats.

Below are highlights from the wide-ranging discussions that took place in both panels.

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Policy Leadership: Republicans

• Rep. Harris said he has been getting emails from people concerned about the possibility of COVID vaccine mandates. This is unlikely for a host reasons, not least the reality that, as Harris points out, there might not be enough vaccines for everyone who wants them initially. Harris said he thinks vaccines are the key to returning to normalcy, and he’s acting accordingly: “I asked to be on the trial. I am a firm believer in vaccinations and I’d like to get vaccinated on day one.”
• Rep. Maycumber highlighted the way COVID disrupted continuous care. During the pandemic, many patients stop receiving preventive care, mental health treatment and cancer screenings. Deteriorating mental health has not been limited to individuals isolating at home. “There is a crisis right now in the mental health community, and then that is going to jails or prisons. You see a lot of those individuals that were not be able to be receiving their treatment continuously go into the system.”
• Rep. Schmick listed liability protections for mental health providers as a priority. With pent up demand catalyzed by the pandemic, he characterized the situation as “Trueblood on steroids”
• Harris said that “if we’ve learned anything through this crisis, people of color, people of lower income have been affected more.” He goes on to say that the state’s public health system can serve as an anchor for these individuals, and that it must be shored up by the Legislature.
• With families quarantining at home, Schmick said an issue has arisen regarding the foster care system: “Some of those kids that are pretty difficult to handle frankly are just being dropped off. Caregivers are not getting the breaks that they need.” Harris concurred and said “holes in the system” exacerbated by COVID have been deeply felt by parents of children with disabilities.
• Schmick said nursing homes that provide service to Medicaid recipients need additional financial assistance. While these nursing homes did get a bump in reimbursement rates early on, it ended on September 1st. The bump decreased from about $25 to about $5 per day. Actual costs from the nursing homes are somewhere between $55 and $58 a day. So, were’ squeezing them with all these extra costs of COVID…it puts them in a bad spot and I think it’s something we do need to address.”
• Schmick said the Legislature should take another look at the drug formulary, or Apple Health Preferred Drug List implemented by HCA in 2018, to evaluate its outcomes: “Has that actually derived the savings that we assumed. We’ve had more time now and I think it’s time take a look back. Rarely in the Legislature when we make policy decisions and changes do we ever go back and look if it achieved what we really desired.”
• Maycumber underscored the continued need to increase insurance availability in rural areas.
• On the subject of obtaining personal protective equipment (PPE), Rep. Maycumber recounted a situation that occurred back in February when a fire department in her district, one of the largest in the state, contacted her regarding a shipment of PPE that never came through. Rep. Maycumber said they called the manufacturer and were told the federal government’s order had “trumped” theirs.
• Harris worried that there was still confusion regarding masks. “There are people that just turn to the strangest news sources…we’re in the greatest society for information and yet, people get their information from different resources. If I’ve learned anything out of this, it’s that you’ve got to find out who your listening and you’ve got to find good recourses.”
• Should a special session take place, Rep. Maycumber wants to work on legislation that would clear up questions over liability protections for health care providers, schools, and others.
• Schmick said the Legislature will probably have to take up a proposal on premium taxes for private carriers, of which there have been several.
• Hospitals in rural areas have had a fairly steady workforce, save for people in supporting roles (CNAs, janitors, etc) which have been more difficult to keep filled. Continued monitoring is needed, said Schmick.
• What are the effects of the budget on health care and mental health service payments in 2021? Schmick says the state can’t go backward, especially on Medicaid reimbursements: “Too many people depend on that, and we’ve got to make it work. I think there’s a lot of pent up demand for substance abuse counseling in that area. When that demand is there we’ve got to do the very best we can to help those folks…I’d like to increase the reimbursement rates for the Medicaid population. When we don’t do that, we just shift the cost to others.
• Both Harris and Schmick underscored the need for more policies designed to help the Department of Health sharpen their data reporting mechanisms.
• Harris acknowledged that the budget hole would create pressure to make cuts, but that cuts impacting the Medicaid population should be a last resort. Schmick concurred.

It’s just my preference that we do not go backwards on Medicaid. I can see that coming and I just, I don’t want to do it,” said Schmick.

Policy Leadership: Democrats

• Rep. Riccelli said that COVID has further displayed that access to affordable housing and food should be considered health care issues.
• With the rise of telehealth, access to broadband is a matter of not just education equity, but health care equity, said Rep. Riccelli.
• Sen. Cleveland said the focus on a broader picture of health, a picture that includes social determinants, presents challenges to policymakers as they focus on ensuring the state’s response to COVID is adequate.
• Sen. Keiser mentioned an interim Senate committee in which members worked to offer a menu of options for legislators to take into session, including legislation to provide health care system pandemic readiness, a PPE stockpile approach, telehealth parity, and health exchange subsidies for the newly unemployed.
• Sen. Randall underscored the need to craft policies that consider social determinants of health, especially in the wake of pronounced racial inequities among COVID cases: “Communities that have already had the roughest access to health care are hit hardest by the pandemic, they are hit hardest by losing their insurance because of losing their jobs, they are hit hardest by a lack of access to health care near them, they are hit hardest by the ability to pat for gas to get to those appointments. Folks are really struggling.”
• Looking ahead to upcoming budget decisions, Sen. Randall said the Legislature needs to learn from the last recession by avoiding implementation of a “cuts only budget” that nixes programs Washingtonians depend on. Said the Legislature should pass a budget that includes investments in social determinants and more.
• While qualifying that neither party in particular is to blame, Riccelli said the Legislature needs to “look in the mirror about how we systematically, not with any bad intentions, defunded public health over the last few years.” Said investments in public health as a first line of defense needs to be built back.
• Keiser said she still has PTSD from making cuts during the Great Recession as chair of the health care committee:

I’m not going to do that again. I’ve told everybody I’ve met with, I cannot endure another nightmare like in 2009, when we basically defunded the basic health health plan and took it down. I still feel guilty about that.”

• Do we need a special session this fall? Keiser says that from a health care perspective, until the future of the Affordable Care Act is clear, the Legislature should not go into a special session. Outside of emergency supplemental budget work that might be necessary after the election, Keiser said she hoped the Legislature would not need to reconvene before January.
• Cleveland also expressed trepidation about “moving too hastily” into a special session until more information becomes available regarding another potential federal relief package. Thinking back to cuts made during the Great Recession, Cleveland said the priority of the Legislature should be to maintain as much stability as possible during this period of uncertainty.
• Keiser says Washington’s social safety net has been part and parcel of how the state has soldiered through the pandemic thus far, but would need to shored up even more during the next session.
• Riccelli was unequivocal that next session will be “scoped down and budget focused.” Areas for investment will be sought out and potential reductions will be looked at through an equity lens, he said.
• Keiser is working on legislation for next session that would establish “health equity zones” – designating geographic regions where high proportions of inequity in health access, coverage, and outcomes exist. After designating these zones, ground-level public health programs would be put into place that would empower trusted partners in communities to engage with residents.
• Randall said police accountability legislation, such as the “common-sense, popular reforms” being worked on by Sens. Dhingra and Pedersen, should be heard next session.
• Cleveland said the state’s direct COVID response and all the issues that fall under that umbrella, such as vaccine distribution and adequately funding public health, would remain the Legislature’s foremost priority.
• Riccelli was very concerned about HCA’s proposed cut, which the agency hopes not to make, to the adult dental Medicaid benefit. Over 1 million adults would lose the benefit and it doesn’t make sense from a fiscal standpoint due to the concomitant loss of federal match funding that would occur, Riccelli said.
• The legislators also agreed that the rising cost of prescription drugs would need to be addressed. A Trump executive order related to the 340B program could impact the way low income people receive care and access medication.
• Keiser and Randall both said they are keeping on eye on the activity of hedge funds in the health care system and mergers between health systems that necessitate new regulatory and transparency policies.

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