Mark Sciegaj, PhD

Based on findings from a 2-state study, the authors articulate research-informed action steps for promoting state government roles in the pursuit of a culture of health (COH). The action steps are meant to generate dialogue about what can reasonably be expected from state governments when thinking about health more broadly.

 A 2-state study based on secondary document review and semistructured key informant interviews.

 Archival data were collected and synthesized to create in-depth policy summaries that provided background information and guided the development of semistructured interview protocols. Interviews with state-level stakeholders were recorded and transcribed. Research team members reviewed the transcribed data for major thematic categories and then drafted thematic memos that identified categories that facilitated (or hindered) the state’s movement toward a COH, the findings from which were discussed among all authors. Based on the exploratory findings, the authors then articulated a set of research-informed action steps for engaging state governments in pursuing a COH.

 The state governments of Oregon and Pennsylvania differ in their approaches to and success in ensuring the health of their citizens, and both face similar challenges in their efforts.

 A COH may be easy to conceptualize, but it is by no means easy to accomplish. States face many barriers in pursuing a COH. By understanding both barriers and facilitators of developing a COH and arming themselves with research-informed action steps, those both inside and outside of state government will be better prepared to pursue a COH through state engagement.

The American Journal of Accountable Care. 2019;7(3):4-11

Five years ago, the Robert Wood Johnson Foundation (RWJF) challenged the nation to build a culture of health (COH) to improve health, well-being, and equity.

 To guide this shift from a medical care focus to a broader conceptualization of health improvement and reform, RWJF identified 4 interdependent action areas: (1) making health a shared value; (2) fostering cross-sector collaboration to improve well-being; (3) creating healthier, more equitable communities; and (4) strengthening integration of health services and systems. The COH model is not intended to dictate a specific pathway for action but instead to identify the necessary components of effective action.

Moving toward RWJF’s vision requires engagement, commitment, and a clear fiscal imperative from multiple sectors of society, including multiple levels of government (eg, federal, state, county, municipal, tribal). Although conversations about building a COH are gaining momentum nationally,

 limited studies have been published to date that specifically address the roles or motivations (or lack thereof) of state governments in pursuing a COH.

 More frequently, the challenge of state-level political gridlock has been noted as a barrier to the innovation and change needed to support a COH.

In this paper we summarize findings from a 2-state study (Oregon and Pennsylvania) in which we assessed state government action in the pursuit of a COH. Although they differ in population size and geographic location in the country, Oregon and Pennsylvania have a similar mixture of rural and urban populations, with the US Census Bureau classifying 19% of Oregon’s 3.8 million residents and 21% of Pennsylvania’s 12.7 million residents as rural.

 We combined extant knowledge of these 2 states from the evaluation of RWJF’s recently concluded Aligning Forces for Quality (AF4Q) initiative with new documentation, interview data, and author insights in order to arrive at our conclusions, which we present here as research-informed action steps for promoting state government roles in the pursuit of a COH.

Archival data were collected and synthesized to create in-depth policy summaries that provided background information and guided the development of semistructured key informant interview protocols. Archival data included materials collected and produced as part of the evaluation of the AF4Q initiative

; websites; state health assessments; state health improvement plans; State Innovation Models (SIM) grant materials; state government and departmental organizational structures, budgets, and strategic plans; and materials on nongovernmental state-level organizations working in social determinants of health (SDOH).

The summaries provided a general overview of (1) the political climate of each state government, including its recent political history; (2) state-level priorities, including each governor’s priorities and priorities related to health, healthcare, and SDOH; and (3) where evidence existed of multiple state agencies working together to address COH-related issues. Additionally, the summaries raised issues to explore during key informant interviews.

Semistructured interviews, which were tailored to each respondent, probed if and how major state-level agencies address COH-related issues, the extent of interagency governmental collaboration, and state collaborations with nonstate actors (eg, regional and state-level nonprofit organizations, local governments). Potential respondents were selected based on their roles or were suggested by government employees. Respondents served as deputy secretaries, advisors, directors, coordinators, or policy analysts in state government or held senior leadership positions in nongovernmental organizations. In total, 17 interviews were conducted (8 in Pennsylvania, 9 in Oregon). All interviews were recorded and transcribed.

Several members of the research team reviewed the transcribed data for major thematic categories. Memos were written for each transcript that grouped data by the identified themes. All memos were reviewed by a second analyst and thematic categories were refined based on new insights. Once the interview memos were completed and reviewed, preliminary insights and findings were written and disseminated to the research team for deliberation, which resulted in a high-level evaluation of each state’s undertaking in the 4 COH action areas, from which the authors developed research-informed action steps for promoting state government roles in the pursuit of a COH.

The results from our analysis are as follows and organized by RWJF’s 4 COH action areas.

Action Area 1: Making Health a Shared Value

As part of this action area, RWJF challenges individuals, families, and communities to work to achieve and maintain health. Specifically, we examined each state’s approach to Medicaid expansion and reforms related to the integration of medical care with interventions that address patient needs that are outside of the traditional scope of medicine, such as behavioral health and SDOH.

In Oregon, universal healthcare coverage has been a legislative goal since the late 1980s,

 and “healthy and safe communities” is among Governor Kate Brown’s 4 main priorities.

 In its most comprehensive health reform effort, Oregon passed bipartisan legislation in 2012 that restructured its Medicaid program, the Oregon Health Plan (OHP), by creating coordinated care organizations (CCOs), local entities that are responsible for providing and integrating healthcare, both physical and behavioral, for OHP beneficiaries. This work was supported by a Section 1115 Medicaid waiver that called for the reduction of per capita spending on healthcare by 2 percentage points in exchange for $1.9 billion in federal funds. This enabled a significant expansion of the Medicaid program and full-risk capitated contracting for the entire covered population.

Since 2012, CCOs have saved an estimated $2.2 billion, reduced unnecessary emergency department visits, and improved preventive care for children and adults.

 Multiple respondents expressed their belief that CCOs are playing a

catalytic role in addressing SDOH across the state. In 2018, Oregon enacted Senate Bill 558, commonly referred to as Cover All Kids, which expanded OHP to include eligible children and teens, regardless of immigration status. All other eligibility criteria, such as household income, remain the same.

Conversely, Pennsylvania’s approach to health reform appears to be fragmented, with no unifying goal or strategy. Unlike Brown, Pennsylvania Governor Tom Wolf does not specifically list health among his top priorities, which are defined as “jobs that pay, schools that teach, and government that works”; however, “improve health care” is listed as part of the governor’s action plan.

 Additionally, Pennsylvania’s legislature has been historically split on many health policy reform issues.

 Although Pennsylvania expanded Medicaid in 2015, the mechanism by which that expansion took place changed as a result of the 2014 gubernatorial election. The Section 1115 Medicaid waiver approved under former Governor Tom Corbett was withdrawn by the newly elected Wolf 1 month after it became effective in January 2015. Wolf then implemented a more traditional Medicaid managed care program, HealthChoices, in the summer of 2015. Since implementation began, the state has encountered multiple legal battles regarding the bidding process for managed care organizations to provide physical health services. In April 2018, a state court ruled in favor of the insurers, finding that the state violated its procurement code.

 Early data on HealthChoices show increases in enrollment, health status, utilization, and expenditures, as well as a decrease in hospital uncompensated care; there is no evidence of other cost or quality impacts to date.

 Most recently (July 2019), Wolf signed legislation that creates a state-based health insurance exchange, which is expected to be operational as early as January 2021. The new exchange includes a reinsurance fund that will directly cover some of the healthcare costs for high-cost individuals, which will reduce the premiums for others insured through it.

One area where Pennsylvania is attempting to reform the health system is rural healthcare. In 2015 Pennsylvania received a SIM grant from CMS to transform rural hospitals to be more effective and efficient in their care delivery (described further under Action Area 4). However, this initiative is more of an artifact of the state responding to a specific call for proposals and not a part of a comprehensive strategy.

Action Area 2: Fostering Cross-Sector Collaboration 

Under this action area, RWJF is interested in the number and quality of partnerships, investments in collaboration, and creating incentives and methods to encourage ongoing collaboration. Within state governments, fostering cross-sector collaboration can be accomplished by either promoting interagency collaboration or restructuring governmental agencies in a way that brings complementary services under the same administrative umbrella. We hypothesize that state government support of cross-sector collaboration, either directly through allocation of monies or indirectly through organizational structure and leadership priorities, affects both the robustness of collaborative efforts and the ultimate success of the work. We found scant evidence that either state supports interagency collaboration through the direct allocation of financial resources. However, both states have attempted to facilitate cross-sector collaboration by reorganizing state-level agencies.

In 2009, the Oregon legislature passed legislation that incorporated the departments of Public Health and Addiction and Mental Health, which were previously housed in the Department of Human Services, into a new agency called the Oregon Health Authority (OHA).

After nearly a decade in existence, the Oregon Health Policy Board approved reorganizing OHA by realigning Medicaid operations and policy as a distinct section in the Health Systems Division, thereby realigning the behavioral health programs that are currently spread among the Health Systems, Health Policy, and Public Health divisions. The changes were made to increase accountability in Medicaid operations and elevate the behavioral health program.

 Pennsylvania has struggled with passing legislation to reorganize state agencies. As part of his 2017 budget, Wolf proposed combining 4 agencies—the departments of Health, Aging, Drug and Alcohol Programs, and Human Services&mdash;into a single department. The proposal was met with opposition from advocacy groups and legislators and never implemented.

 In his 2018-2019 budget proposal, the governor proposed the unification of the departments of Health and Human Services,

 but the proposed merger did not make it into the final appropriations bill.

Beyond formal reorganizations, it was noted that when interagency collaboration took place, the efforts in both states did not always involve people at the right level, signaling a lack of perceived value by leadership. Speaking about an interagency work group, one respondent stated, “I’m not sure that the people around the table are [at] a high enough level to be able to make some significant decisions. I think they’re [at a] high enough level to make smaller decisions.” Another respondent frustrated with his interagency collaboration experience noted, “I’ve been involved with the [name redacted] for 10 years and I feel like we never get anywhere.”

Action Area 3: Creating Healthier, More Equitable Communities

Under this action area, RWJF is focused on addressing environmental and policy barriers that prohibit people from living in good health. Both Oregon and Pennsylvania have state-level offices that focus on health disparities and inequities, operate multistakeholder groups to address health disparities and inequities, and grapple with creating healthier, more equitable communities. Oregon’s Office of Equity and Inclusion—formerly known as the Office of Multicultural Health Services&mdash;was created in 1993, whereas Pennsylvania’s Office of Health Equity (OHE) was established in 2007. Beyond racial and socioeconomic inequities, each state wrestles with geography-based inequities, with urban versus rural inequality being a common theme.

Oregon established 3 Regional Health Equity Coalitions (RHECs) in 2011 and added 3 more in 2014 using SIM grant funds. RHECs are tasked with defining their region, priority populations, and focal issues and “power mapping” to figure out the best way to move toward health equity. Several RHECs work closely with their local CCOs to influence policy and system changes. The increased use of medical interpreters was cited as an example of positive change that resulted from a RHEC working with its local CCO.

A unique and, at times, controversial feature of RHECs is that they were designed to focus on communities of color.

 RHECs face pushback from people at all levels of government and across agencies, including within OHA, related to their focus on communities of color versus low-income communities and the speed at which they accomplish results. According to one respondent, the variation in levels of buy-in “usually correlates with more urban versus rural or frontier areas” and is amplified because many Oregonians view the state as “a bunch of white people.” Limited resources will likely prohibit the expansion of RHECs.

At the state level, the Pennsylvania Interagency Health Equity Team (PIHET), made up of 13 agencies and staffed by OHE, began meeting in 2017. PIHET does not receive funds from the governor’s office or participating agencies. PIHET maintains an apolitical stance, framing its work around vulnerable communities—most of which are rural&mdash;versus racial and ethnic disparities. A challenge to PIHET’s strategic planning is that “you have to look at things in 4-year chunks” because changes in administration can have implications for staff, project goals, and funding.

On a regional level, the North Philadelphia Health Enterprise Zone (HEZ) launched in 2016 through a partnership among the departments of Human Services and Education, the City of Philadelphia, and area hospitals, universities, and community partners. Philadelphia is home to the highest number of Medicaid recipients in Pennsylvania, with 13% of the state’s Medicaid recipients residing in North Philadelphia, where nearly a third of all residents live in poverty. The HEZ focuses on 4 key socioeconomic factors: health, community, education, and technology. In 2018, the HEZ received $11.8 million in financial support from the state.

Although monies to address health disparities and inequities appear to be tight in both states, lack of funding is just one of many challenges and not necessarily the most critical one. According to one respondent, “The underlying challenge in all of this is really how do you support the community, how do you support the individuals in the community in terms of economic development, education, job creation, health literacy, and really getting your arms around poverty and the effects of poverty. If you were to ask me to rank the challenges, I don’t think funding would be on the top of my list.”

Action Area 4: Strengthening Health Service/System Integration

As part of this action area, RWJF focuses on integrating health services and other systems in an effort to provide comprehensive and high-value care. Strengthening the integration of health services and other systems is intentionally part of Oregon’s health transformation plan. As part of its Section 1115 Medicaid demonstration, Oregon developed a theory of action model that describes OHA and CCO actions that are associated with 6 transformation levers. Specifically, in relation to lever 3, which focuses on integrating physical, behavioral, and oral healthcare, OHA sets CCO contractual requirements for integration, community health assessment, and quality improvement projects. Additionally, CCOs are required to take steps to integrate and transform care, engage with the community, and complete quality improvement projects.

As the first 5-year contracts for CCOs came to an end, OHA solicited input from Oregonians and commissioned an independent analysis of Oregon’s 2012-2017 Medicaid waiver.

The next phase of Oregon’s health system transformation has been dubbed CCO 2.0. As part of the transformation, Brown asked the Oregon Health Policy Board (OHPB) to obtain input and provide more specific recommendations to the OHA on “how the state and CCOs can further transform health care to continue to improve health outcomes, increase value, and hold down costs.” Specifically, the OHPB was challenged to focus on 4 areas: (1) SDOH and equity, including building stronger partnerships between the healthcare system and other social systems; (2) increasing value-based payments; (3) improving the behavioral health system; and (4) maintaining sustainable cost growth.

In contrast to Oregon’s use of CCOs, the Pennsylvania Medicaid program is broken into 3 components: physical health, behavioral health, and community choices. Components are managed by different entities within the Department of Human Services (ie, Office of Medical Assistance Programs, Office of Mental Health and Substance Abuse Services, and Office of Long-Term Living) as well as the Department of Aging, creating a patchwork approach to providing services to beneficiaries.

Perhaps the best example of an attempt to integrate health services and systems in Pennsylvania is the state’s Rural Health Model. This CMS grant, which is being administered by the Department of Health, is intended to provide rural hospitals with an opportunity to transition from fee-for-service, volume-based reimbursement to a multipayer global budget that is intended to provide predictable funding to maintain crucial health services, improve population health outcomes, increase quality of care, and lower costs.

 As part of the program, hospitals will lead the development of transformation plans with input from community-based organizations and local public health departments, then submit their plans for approval. Population health, including SDOH and opioid abuse, is predicted to be a critical part of each plan.

Action Steps for Engaging State Governments to Achieve a COH 

We used our examination of what Oregon and Pennsylvania were undertaking in each of the 4 COH action areas to articulate 5 action steps to strengthen states’ roles in the pursuit of a COH. Given the small and purposive sample selection, the findings are exploratory and are not generalizable to all states’ efforts to improve or maintain the health of their populations. Instead, the action steps that follow are meant to engender discussion and to guide action until more research is conducted on states’ efforts.

Understand economic drivers and special interests. 

Both Oregon and Pennsylvania appear to value the idea of integration and have (with limited success) attempted to take steps toward the integration of health services/systems, and in some cases (eg, CCOs, the Pennsylvania Rural Health Model) require it. However, healthcare services are “big business,” consuming almost 20 cents of every dollar spent in the economy.

 Healthcare-related programs, such as Medicaid and the provision of health benefits for state employees and retirees, have for many years consumed the lion’s share of state budgets.

 Moreover, the healthcare sector is the largest employer in the United States,

 and healthcare jobs are projected to grow faster than jobs in the general economy.

 The many special interests associated with healthcare include health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and the associated businesses that exist because of a lack of integration, such as behavioral health carve-outs and disease care management programs. These special interests, which may feel threatened when states work to implement RWJF’s broad vision of a COH, are vocal when it comes to changes in their respective segments of the healthcare industry, spending more than $711 million a year on lobbying

 to protect their interests and to build strong relationships with the legislators and executive branch leadership who ultimately make the decisions regarding program integration and consolidation. In order to mitigate the influence of special interests, it is important for stakeholders pursuing a COH to identify special interests that may be affected by decisions and to be armed with information, including statistics and budget forecasts that illustrate the impact on the state and its citizens of a broad-based COH approach, as well as the opportunity costs of sticking with a more narrowly defined siloed status quo approach (described later).

Calculate the “opportunity costs” of not achieving a COH. 

Although our 2-state comparison found that Oregon and Pennsylvania are both pursuing efforts in the COH framework, Oregon has a more direct statewide vision related to health, and its efforts appear to be more coordinated and aligned than Pennsylvania’s. To motivate states toward a COH framework, it is important to provide a clear vision of what would look different if a COH was achieved, including health, welfare, and economic consequences. Providing such a vision will help to frame what economists call the “opportunity costs” of not achieving the proposed change, making it more difficult for various interests to oppose such change because to do so would be effectively making a statement that these opportunity costs are valued differently—or not valued at the same level as by those proposing change.

The opportunity costs of a COH should be framed first and foremost in terms related to the health and welfare of a state’s population, and then in economic terms. Individuals or organizations wanting to motivate state COH efforts could start the opportunity cost discussion using a set of 2018 COH outcome measures, including individual well-being, preventable hospitalizations, disability-adjusted life-years related to chronic disease, incarceration, family healthcare costs, and others, that were developed by RWJF and RAND.

 By using sound research evidence to estimate and report these measures, the opportunity costs of the status quo become clearer. The economic consequences are the extensions of resources that state governments spend and will continue to have to spend to address these poorer outcomes—for example, the increased costs to Medicaid programs because of a higher prevalence of chronic disease or unnecessary medical services use. Lessons from Oregon may be helpful on this point: As we reported, Oregon has saved an estimated $2.2 billion, reduced unnecessary emergency department visits, and improved preventive care for children and adults since 2002.

 Importantly, once the state’s opportunity costs are monetized, they can be expressed as dollars that are otherwise not available to state governments to accomplish other important policy objectives, such as spawning economic development, improving public education, and refurbishing a declining transportation infrastructure.

Clearly identify budget externalities across silos and the potential efficiencies of better integration. 

Most state governments are organized around a historical structure that results in various programs and budget lines being housed in different agencies and departments, despite having important externalities for programs and budget lines in other departments and agencies. The organization of Medicaid in Pennsylvania provides a classic example of a program that is broken into multiple components and housed across multiple agencies. Using the opportunity cost concept described earlier, critical questions for state governments to ask are if and how consolidation or integration of programs with significant externalities could result in better outcomes for those receiving state-sponsored services and if the provision of these services could be done more efficiently from a budgeting perspective.

Certainly, there are political “turf” issues to making these changes, as we noted with Wolf’s multiple attempts in Pennsylvania to consolidate departments, including those that house the various components of Medicaid. Furthermore, the potential efficiencies related to consolidation often are experienced over a time horizon that expands beyond a single budget year and potentially an election cycle. Consequently, intertemporal budget modeling and forecasting is necessary to calculate the impact of such changes on state budgets—in both the near and long term. No published resources appear to be available to assist states in this area, so a concrete suggestion would be for foundations or other interested sponsors to fund advanced public finance models that help states both identify the budgetary consequences of their current approach and provide tools to forecast the budgetary implications associated with potential consolidation and integration of programs and departments.

Understand the political climate and find unifying principles that work across the aisle. 

With widening divisions between Democrats and Republicans on fundamental political values,

 today’s polarized political environment—at both the federal and state levels&mdash;can make it difficult to gain bipartisan support for significant policy proposals. Opposition is often viewed on 2 critical dimensions: political ideology and the implications for entrenched special interests. In the case of a broader vision for health within states and the move to a COH, both political ideology and the impact on special interests are important. Although making the case for bipartisan support is by no means a slam dunk, it seems that 2 simple principles could be leveraged. The first is that maximizing the health potential of every citizen should be a unifying rather than a dividing principle, and the goal of a COH is to accomplish exactly that. A COH satisfies a long-standing conservative value of promoting individual independence (through improved health) while at the same time supporting the modern liberal goal of removing obstacles that prevent individuals from fully realizing their potential. To support this first principle, concrete data on the opportunity costs of maintaining the status quo should be emphasized, as discussed previously. The second principle is that coordination and integration of state programs requiring significant state expenditures is more efficient than the status quo of disconnected and siloed programs, and a reduction in this inefficiency can free up resources that can be used to accomplish other goals. Stated differently, although there may be partisan views on how savings due to the long-term efficiencies of a well-coordinated COH should be spent or allocated, partisan disagreement should not arise on extracting efficiencies due to a poorly integrated system of programs and expenditures related to the health and welfare of the state’s population.

Educate and train leadership on the necessity to break down management and accountability silos in state governments. 

A key barrier to accomplishing a broader view of a COH is change management, which is hampered by years of operating the same way in terms of agency and department organization and reporting and the budgeting process. As part of our research, we found scarce evidence that either state supports interagency collaboration through the direct allocation of financial resources, and when interagency collaboration did take place, the efforts did not always involve people at a high-enough level to be impactful, possibly signaling that state leaders do not prioritize interagency collaboration. However, the change needed to accomplish a COH will require innovative thinking and risk taking, and it must involve key state leaders from multiple agencies. Health system literature provides evidence that this type of cross-department collaboration is possible but does require the visible support of leadership.

 With the support of committed leaders, perhaps an external sponsor, and examples of organizational transformation in other institutions and industries, state bureaucrats and staffers can enhance their ability to think innovatively, take risks, manage change, and embrace interagency collaboration leading to a COH.

Although RWJF’s vision of a COH is perhaps easy to conceptualize, it is by no means easy to accomplish. States face many barriers in pursuing a COH, but they also have the opportunity to make deep and lasting impacts on the health of their citizens. Although not generalizable, the findings and action steps presented here provide a starting point for dialogue, action, and future research about states’ roles in promoting and supporting a COH.

 Center for Health Care and Policy Research (DPS, JMV, BL) and College of Health and Human Development (MS), The Pennsylvania State University, University Park, PA.

 Funding for this research was provided by the Robert Wood Johnson Foundation (RWJF) and by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through Grant UL1 TR002014. The content is solely the responsibility of the authors and does not necessarily represent the views of RWJF or the NIH.

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