As young aspiring health professionals become interested in learning about health policy, they often look to take advantage of one of the many opportunities to work on policy in the heart of our federal government, Washington, D.C. From the Center for Medicare and Medicaid Services office in Baltimore to the Health Resources and Services Administration offices in Rockville to the endless lobbying firms, think tanks, policy institutes, advocacy organizations and non-governmental organizations, it can seem like health policy races through the Capitol’s halls and is on the tip of every Congressional staffer’s tongue. To some extent, this is true. According to OpenSecrets, there are over two thousand registered health care lobbyists in Washington who spent over five hundred million dollars a year to lobby Washington in 2017. Many federal regulatory agencies are located in the D.C. metro area and they interact closely with these vested interests.
Even as a powerful health care regulatory network has established itself in the D.C. area, a surprising amount of health policy is left to be legislated by state and local agencies. According to the Pew Trust, the Affordable Care Act-established individual market, Medicaid, the Children’s Health Insurance Program, state government employee insurance and the health care of prisoners are all given broad discretion at the state level. These programs alone insure over one hundred million Americans and their impact shows on the state budget. Sixteen states spend over 30% of their state dollars on only Medicaid, let alone the other insurance programs. The flexibility offered to states allows them to experiment with their policy to create solutions that are tailored towards their state’s patients. In California, this allowed the state to create unique Medicaid implementations for every county: some counties have their own county-run health plan which works in tandem with local hospitals, others have a set of commercial plans that compete for Medicaid patients and others maintain both a commercial and county-run plan.
This discretion can lead to some unique challenges as well. A survey conducted by a student at Columbia’s Graduate School of Journalism found that 97% of inmates had not received treatment for their Hepatitis C as of March 2018. This is due to the difficulty of carving out state funding for Hepatitis C treatment since it comes directly out of the state budget. Due to pushback from advocates, California passed a bill allocating $176 million to treat more than 22,000 inmates with Hepatitis C and expand access to Hepatitis C treatment among the poor. The activity isn’t just on the legislative side. For example, the Trump administration has been pushing telehealth and has thus given state health departments broad discretion on how they would like to include telehealth as a covered benefit within their state Medicaid programs. The Center for Connected Health Policy is quoted, “although states occasionally use similar language in their policies, no two states are alike in how telehealth is actually defined and regulated.”
I was fortunate enough to witness the action happening at the state level firsthand. This summer, I had the opportunity to work at California’s Department of Health Care Services (DHCS) as part of the Benefits Division, which writes policy for Medi-Cal’s fee-for-service program. In the process, I found out that, for a state like California, the number of interests trying to lobby local health policy may rival the political engagement seen at the federal level. The engagement itself also felt more immediate given that the region we were attempting to set policy for was much smaller than the entire country, and that the regional relationships were much tighter. During my second week at the office, I remember sitting in on a tense stakeholder meeting with a set of advocates for a Medi-Cal covered wellness program. These advocates had been hawking the program lead for a meeting to critique a bill which may help Medi-Cal recipients more expansively use the program. The advocates passionately brought their case to the table, bringing providers to our office to explain how the proposed legislation would help them reach more Medi-Cal recipients. Unfortunately, as they walked through each item of the bill, our team had to explain how almost every single item was out of our scope because of federal regulations or the limitations of our staff. Regardless, I was surprised to see the commitment that the DHCS had to effective stakeholder engagement learning that policymakers preferred to critique bills advocates were proposing before they brought it to legislature.
The week after, I attended one of the classic “intern lunches” held around the Capitol; this one was conveniently themed around health policy and law, and the day’s topic was Medi-Cal. Amused by the coincidence and deeply conflicted by my desire for free food, I showed up to the event, held at a nearby health policy lobbying organization. The lunch’s presentation began with an overview of major Medi-Cal legislation in the past year but quickly transitioned to a thorny fight the organization was having with the DHCS over the description of a specific covered benefit. Sitting there dumbfounded, I tried to eat my falafel and rice plate without showing any expression on my face as the representative tore into the DHCS’s current policy. I was quite shaken after that lunch and so I asked my supervisor about the legal battle. To my surprise, the office was currently discussing the disagreement and they agreed with the lobbying group but didn’t think the policy needed a change. That day, I had learnt just how close policy battles are at the local and state level. More often than not, local advocacy organizations will be in constant conversation with state and local health departments since these offices have so much more unilateral power at the local level.
Health policy can feel like 2018’s hottest topic and many students are looking for a way to learn more. I encourage students to think beyond the policy they see in Washington, D.C. to the laws governing their communities. While news stories seem to focus on federal policy, health policy’s jurisdiction is evenly balanced between the federal and state level, giving students an opportunity to work on interesting policy wherever they happen to be. Coming out of my own internship, I have developed a more nuanced understanding of the balance of power between the national and local level and how there are a variety of ways for students and professionals to help create productive policy. Health and pre-health students alike can find a riveting health policy experience right under their noses.
Ishaan Shah is a third-year student in the College of Arts & Sciences at Washington University in St. Louis, majoring in biology and political science. He comes from Cupertino, California. You can reach out to him on Twitter at @ishaantshah.
