Healthcare in Delaware’s 150th – What to Look for after the State of the State

Delaware Governor John Carney delivered his third State of the State address yesterday, January 17th, in the Senate Chamber. For the healthcare world, what was in it was just as interesting as what was not in it. Highlights included re-emphasis of his existing benchmark proposal as well as Lt. Gov. Hall-Long’s work on mental health and addiction. Looking forward, he signaled a shift in focus to promoting healthy lifestyles, stating support to “raise the age for purchasing cigarettes from 18 to 21.” We’ll unpack these a little more below, but interestingly what didn’t make it in there was any talk about the outcomes of the Medicaid Buy-In Task Force (to not buy the lede – Delaware may become an individual mandate state) or the Primary Care Collaborative, both of which released major reports just a few weeks ago.

Let’s quickly unpack the four paragraphs with healthcare content actually in the Governor’s thirty six minute address. First, the benchmark. This benchmark, modeled off of Massachusetts’s efforts, is a total cost of care measurement and transparency effort that left the realm of idea and entered implementation through Governor Executive Order 25. More information on implementation can be found here, but in short, it’s an effort to pressure healthcare entities in the state to lower their cost inflation rate to match the state’s growth rate, as well as focusing on quality metrics such as diabetes, obesity, and cardiovascular disease rates. Which does logically lead into the healthy lifestyle emphasis in the State of the State.

That lifestyle emphasis likely follows from Delaware’s continuing focus on addressing social determinants of health and creating a healthy population. Easier said than done, of course. One major existing initiative that he could have mentioned, but did not, was the work of the Primary Care Collaborative. The Primary Care Collaborative represents ongoing efforts from SB227, designed to stem the tide of primary care collapse. Key in ongoing talks was a recent report from the Primary Care Collaborative. Among the several recommendations, including following the path Rhode Island has carved to invest 12% of Delaware’s total spend in our primary care infrastructure, is directing much of that investment into tools like chronic care management to reach patients with the exact chronic conditions listed in the benchmark’s quality metrics. There is an obvious connection that could have been mentioned.

Which is not to say that support for Tobacco 21 was not a welcome surprise. The data are clear that tobacco use remains a major health risk. We are layered with news that vaping is far from being a net smoking cessation tool and that it has instead created a new generation of teen nicotine users so the timing is exactly right to raise the age for access to tobacco products. It's a nice complement to the FDA efforts to crack down on vaping devices and sugary vaping fluids. The one quibble to look for is if the Governor’s support will narrowly focus on raising the age for cigarettes only, or if it will reach all tobacco products. While the latter is far and away more likely and the state of the state was simply shorthand, it will be a quirk to look for. Sending a generation of teen nicotine addicts from vaping to cigars, chew, or snuff would be a strange public health outcome indeed.

On public health, the Lt. Governor’s signature Behavioral and Mental Health Consortium was given a welcome nod. Delaware experienced as 12% increase in overdose deaths last year. Seeing the overdose system of care implemented is important.

[Over the next few weeks, we’ll also be outlining and looking back to Delaware’s decade of efforts to address opiate addiction, as well. Be sure to check in.]

Lastly, the outcome of the Medicaid Buy-In (MBI) Task Force failed to make the cut. The outcome of the Task Force belies the Task Force name, but it is still worth talking about. The Task Force early in its work decided that a MBI would be too costly and too risky as to potential market destabilization. However, it decided that its purview was really about lowering insurance costs as much as exploring MBI. In that vein, it examined and ultimately adopted a recommendation to seek a waiver for a reinsurance program, funded in part by implementation of a state-level individual mandate. The mere phrase will be sure to spark partisan debate.

Watch this space as these topics and others come to the fore during the 2019 legislative session.