Toward a Healthy Future 2018 ANNUAL REPORT

TABLEOF CONTENTS

4 | Letter from the Executive Director and Board Chair

5 | Year One by the Numbers

6 | United States of Care in the States

8 | Policy Resources

10 | Case Studies from the Field

12 | United States of Care’s Public Opinion Research

14 | Driving the Health Care Conversation

15 | United States of Care in the News

18 | United States of Care Inaugural Convening —The Path Ahead: A Road Map for American Health Care

19 | Staff and Fellows

20 | Board of Directors

21 | Founder’s Council

22 | Support DEAR FRIENDS,

United States of Care was founded on a vision that so many Americans share but that seems, to many, to be out of reach: affordable health care for every American.

Recently, Americans have seen their health care security become the subject of one of the longest political standoffs that the country has seen. For most Americans, their objectives are simple: to be able to afford to take care of their families, keep them healthy, and know that no one—no Congress, no insurance company, no politician—will take that away. That’s where United States of Care, completing its first year of operations, is focusing our work—affordable health care for every American that will be a durable legacy.

The question for the country will increasingly not be about whether Americans should have the important protections of health security that are fundamental to happiness and prosperity, but how and when.

United States of Care was founded on the vision that this can and will happen if millions get engaged and have a voice, if policymakers are given tools and support, and if people come together with their expertise around the best ideas that can unite us in these simple goals.

Policymakers need to get busy advancing ideas that keep more people healthier, connect them to primary care and mental health resources, make care more affordable, and get rid of the horrible choice too many Americans face, of having to choose between health care and some other expense in their lives. United States of Care will help by supporting policies that work for the people they are intended to serve, that won’t be easily overturned each election, and can be improved as more is learned.

A vital ingredient for United States of Care is to be sure that everyday Americans have their voices heard—so that elected representatives can be accountable to them for policies that provide affordable, hassle free health care—not special interests.

The best ideas for covering more people more affordably must win. United States of Care believesthe states have the best near-term opportunities to create and implement new ideas that bring affordable care to more people. In 2019, like 2018, United States of Care will put the resources of the organization, including the knowhow of Founder’s Council members, to work, helping develop and pass big new ideas in states. Successful approaches can become better models for good policy in 2020 and beyond.

United States of Care represents a vision of a positive and more unified country that allows its residents to focus on better health and a better life by eliminating the insecurity and struggle of not being able to afford health care. The Founders and supporters have come together because we believe it’s time to do something that extends beyond the self-interest of any one participant and that health care does not need to remain politically divisive if the right building blocks are put in place.

For all the great science and medicine in the United States, there are too few Americans who believe they will be able to access those resources when they are most needed. United States of Care enters 2019 grateful to the many Americans who are working for a next generation health care system, one that must be centered on the lonely voice of the mom with the sick child, the small business owner with too big of a deductible, and the teenager with no source of care but an overcrowded emergency room.

On behalf of United States of Care, we are excited about 2019 and pledge to do our part to realize a future where the United States can become the healthiest and most secure country possible.

EMILY BARSON ANDY SLAVITT Executive Director Chair, Board of Directors United States of Care United States of Care

4 UNITED STATES OF CARE | 2018 ANNUAL REPORT Year One by the Numbers A Pressing Issue

28million only 36% Americans have no 3 in 10 Americans of the public believe health coverage report problems that government paying medical bills policies reflect the view of most Americans

A Growing Consensus

HEALTH CARE IMPACTS VOTES MEDICAID EXPANSION MEDICAID BUY-IN SHOULD HEALTH CARE SHOULD BE IMPROVED HEALTH BE A PRIORITY AFFORDABLE

82% 52% 78% 88%

of people said health of people believe that of people believe that of voters think that they care was important to Medicaid expansion Medicaid buy-in should and their neighbors their vote in the 2018 has positively impacted be a priority for their should have an midterm elections their state’s health care state legislature affordable, regular source of health care United States of Care’s Impact

States Impressions Engaged on Twitter 29 With 3.5M

Founder’s New Twitter Council Followers 85 Members 11.1K

UNITED STATES OF CARE | 2018 ANNUAL REPORT 5 UNITED STATES OF CARE IN THE STATES

United States of Care has developed a comprehensive, tailored approach to building relationships at the state level that combines technical expertise, strategic partnerships, and tactical and organizational support. In 2018, we conducted a “listening tour” with more than 20 states, and learned there is momentum for change. In the coming year, we look forward to deepening our engagement at the state level and expanding our strategy to additional areas.

State site visits State relationships formed

Developments over the past year show the potential of state level approaches to expanding health coverage and limiting costs to patients, in both red and blue states.

14 states at least 9 4 states 28states are pursuing states have a moved to expand passed 45 laws Medicaid buy-in comprehensive Medicaid in 2018 to control through studies or law to protect prescription legislation consumers from drug costs surprise bills

6 UNITED STATES OF CARE | 2018 ANNUAL REPORT “I believe that the voices of those directly affected by health care decisions should be the ones leading the conversation.”

— ELENA HUNG, PARENT ADVOCATE, PRESIDENT AND CO-FOUNDER OF LITTLE LOBBYISTS

UNITED STATES OF CARE | 2018 ANNUAL REPORT 7 CASE STUDIES FROM THE FIELD

NEW MEICO

United States of Care’s first strategic engagement in a state is a partnership with advocates in New Mexico to expand affordable coverage via a Medicaid buy-in proposal. We hope New Mexico can serve as a model to inform the dozen other states looking at Medicaid buy-in as a possible route to expanding affordable coverage. New Mexico may open Medicaid to paying customers

United States of Care’s involvement is (MORGAN LEE, 1/30/19, ASSOCIATED PRESS) bringing needed coordination and a campaign-like-mindset and urgency to the project that has the potential to provide tens of thousands of New Mexicans with truly affordable coverage. In addition to our existing offerings of policy development assistance, stakeholder support, strategic Medicaid buy-in program guidance, and access to our network proposed at state legislature of experts, United States of Care hired (KAI PORTER, 2/8/19, KOB 4) a project manager on the ground, and conducted state-based public opinion research to better understand how New Mexicans respond to the proposal. Our initial focus groups offered promising feedback on the buy-in idea, suggesting that the issue has not yet hardened along partisan lines. “It’s so helpful not to be

Special thanks to founding champions of alone in this process.” United States of Care New Mexico, — BARBARA WEBBER, EXECUTIVE DIRECTOR OF J. Mario Molina, M.D. and John C. Molina. HEALTH ACTION NEW MEXICO

8 UNITED STATES OF CARE | 2018 ANNUAL REPORT Analysis Shows Great Disparities

MINNESOTA Between Black & Whites In Minnesota (1/16/19, CBS MINNESOTA)

Minnesota has been a national leader in health care policy and innovation, ranking consistently as one of the top ten healthiest states in the country. Yet this strong performance obscures serious inequities in outcomes, among people of color, Despite progress, ethnic health Native Americans, people with disabilities, disparities persist in Minnesota people with low socioeconomic status, and (JEREMY OLSON, 1/11/18, members of the LBGTQ+ community, as MINNEAPOLIS STAR TRIBUNE) these populations experience worse health outcomes than their socially-advantaged peers. While increasing access to medical services is critical to closing these gaps, we now understand that most of our health is determined outside of the doctor’s office. “As a former state legislator, To address these issues, United States of I can attest firsthand that Care is spearheading an ambitious effort to help Minnesota become the first state to there is a need for resources eliminate gaps in health outcomes due to and expertise to help states social disadvantages by 2030. tackle complex policy issues. United States of Care will utilize Minnesota’s existing abundance of expertise, resources, United States of Care is and initiatives on health equity to close responding to this need by these health gaps, by creating a shared strategy and unifying goal. following the lead of folks

United States of Care has already convened on the ground, identifying numerous organizations and leaders that are working to address social factors that existing gaps and forming contribute to health inequities. Bringing strategic connections to together all the expertise in Minnesota behind a shared goal of eliminating health help states make meaningful gaps in a decade will make this audacious vision achievable. The first step to this vision progress on health policy is a feasibility study and environmental initiatives.” scan of Minnesota’s existing efforts to address the social determinants of health. ­— HON. JOE HOPPE, STRATEGIC ADVISOR FOR United States of Care is working with The STATE AFFAIRS AT UNITED STATES OF CARE Amherst H. Wilder Foundation’s divisions AND FORMER MEMBER OF THE MINNESOTA HOUSE OF REPRESENTATIVES. of Wilder Research and Wilder Center for Communities, as well as a steering committee and advisory committee to conduct this study.

UNITED STATES OF CARE | 2018 ANNUAL REPORT 9 POLICY RESOURCES

United States of Care is committed to identifying and developing new solutions that expand access to affordable care. Our policy resources serve as a guide for policymakers and health care stakeholders, providing actionable and sustainable approaches for improving the health and well-being of Americans. Our policy resources are available in full on our website: usofcare.org.

Medicaid Buy-In: State of Play 2018 To: Interested Parties From: Kristin Wikelius, Senior Director of Policy Allison O’Toole, Senior Director of State Affairs Health Care Re: Medicaid Buy-in “Surprise” Medical Bills: Prescription Drug Prices: Problems, Solutions, The National Outlook Key Highlights WHAT IS MEDICAID BUY-IN? recent study rating their care a 7.9 on a  Medicaid Buy-in is generating The term “Medicaid Buy-in” is used to scale of 0-10.7 People who became eligible States Opportunities to Protect Patients and What States Can Do excitement from both consumer describe differently structured proposals, for Medicaid under the Affordable Care This brief was authored by Kristin Wikelius, with research assistance from Catherine Jacobson This brief was authored by Meg Garratt-Reed, Director of Policy and Partnerships, with thanks to members of the United States of Care Founder’s Council and network for their valuable review and feedback. unitedstatesofcare.org groups and state governments but all would create a way for some Act’s expansion rate their coverage even interested in improving health people who are not currently eligible more highly than those enrolling in Most people hope and expect that being This increased anxiety may be driven by emergency room with a broken Thanks to battles in Washington, health care has been in the news more When Americans talk insurance affordability and choice. 3 of drug costs is to address the underlying entering the market, and other for Medicaid to purchase Medicaid or Marketplace coverage. A Commonwealth covered by health insurance will protect narrowing insurance networks, a strategy jaw. While the hospital was in his BACKGROUND than ever over the past few years. No matter where on the political  States may explore Medicaid list price itself. forms of patent abuse. about high health care Medicaid-like coverage. Just as no two Fund study in 2016 found that 77 percent them from financial ruin if they are used by health plans to reduce premiums insurance network, he received a spectrum we fall, it’s clear that this is a key issue for voters and families in Buy-in for a variety of reasons, and The price of prescription drugs has costs, what do they mean? states have identical Medicaid programs, of adults with marketplace plans and sick or injured. Sometimes, however, by excluding higher cost providers from $7,924 bill from the out-of-network November. It’s critical for candidates to understand the motivations behind each state’s approach will likely be increasingly been a topic of public Even when a more direct solution isn’t  Medicaid buy-in proposals are likely to 88 percent of those newly enrolled in 6 Expensive drugs that are having health insurance coverage is their networks. These networks, however, oral surgeon who operated on him. that growing energy, and the options available at the state and federal level Premiums: Monthly payments for designed differently to meet the vary from state to state. Medicaid were very or somewhat satisfied concern over the last several years. feasible, however, there are interventions ineffective or have cheaper insufficient to shield people from serious can create limited choices for patients as to respond to constituents’ concerns. health insurance. These costs can be state’s unique needs. 8 A 2018 Kaiser poll showed that 80% that can be effective in mitigating the alternatives. A consequence of with their health insurance. A recent poll financial pressure from medical bills. they seek care. Anxiety around surprise  Patients can still encounter out- particularly significant for individuals  Fourteen states are in various stages of Americans believe drug prices are impact of high prices on certain parties. having an insurance system that  Buy-in proposals aim to make found that 51% of respondents are in favor People with insurance can face not only bills may also be driven by a decline in the of-network providers even if a Overwhelming majorities of voters of both parties and families who don’t receive of exploring Medicaid Buy-in, unreasonable, and a significant majority Depending on the situation they are most protects most consumers from available the relatively robust and of Medicaid Buy-in plan, with only 9.6% copayments and deductibles, but also number of plans offering out-of-network procedure is planned in advance, insurance through their employer, but through studies or legislation. think that Congress and the President urgently looking to address, policymakers cite affordability as a top concern affordable coverage Medicaid opposed.9 unexpected “surprise” medical bills after understanding the cost of the make too much money (over $100,000 benefits in the individual and small- and they have tried to avoid out- 1 typically provides to people who are not doing enough about the problem. at the state level should also consider the drugs prescribed to them is that for a family of four) to qualify for they seek care, even if they were treated group markets. A recent Robert Wood of-network providers. Leanne Lowering Out-of-Pocket Costs Top Health Care Priorities Among Partisans, As states look for opportunities to control don’t otherwise qualify. The goal is Additional attention to the issue has been merits of different proposals that shift the it’s difficult to assign responsibility subsidies to purchase insurance. MEDICAID BUY-IN IS AN at a hospital or health care facility that Johnson Foundation report found that Tiede researched her coverage to Other Priorities Vary by Party insurance costs, stabilize their insurance not to change the Medicaid program APPEALING OPTION FOR STATE driven by media coverage of particularly burden of cost away from consumers and for determining the best balance is in their health insurance company’s Percent who say each of the following things should be a “top priority” markets and provide consumers with POLICYMAKERS the percentage of plans offering out-of- make sure that both the hospital on to other entities, including employers, Cost sharing: Fee paid (including for those already eligible and network. riveting examples, including the case of of price and effectiveness. Patients for Donald Trump and the next Congress when it comes to health care: more options, Medicaid Buy-in is network benefits is decreasing, dropping and surgeon she selected for enrolled. Medicaid Buy-in proposals can appeal Martin Shkreli, who raised the price of health care providers, or the state itself. don’t have the medical knowledge Democrats Independents Republicans copayments and coinsurance) when emerging as a potential solution under from 58 percent to 29 percent in the breast cancer surgery were in someone sees a doctor, pays for to state policymakers for many different People use the term “surprise bill” to a patented drug 5,000% overnight; the necessary to understand clinical Lowering the amount consideration in many states.  In this context, Medicaid Buy-in individual market from 2015 to 2018, and her insurance network. She later THE TYPES OF PRESCRIPTION individuals pay for a prescription, or receives another reasons. Medicaid is an efficient program, describe many different types of medical $94,500 launch price of the first effective differences between products, and health care 64% 65% 70% should not be confused with existing from 71 percent to 64 percent in small received a surprise $800 bill from DRUG PRICING PROBLEMS medical service. and while it occupies significant bills that a patient did not expect to treatment for Hepatitis C; and the recent many doctors and pharmacists The results of the recent midterm programs in many states that allow group market plans over the same time the anesthesiologist, who was out- Lowering the cost of 55% 61% 67% percentages of states’ budgets, when receive. Most commonly, however, it dramatic price increases for Epi-pens and  High and increasing prices don’t view it as their responsibility prescription drugs The direct costs of care: If a consumer elections show that health care is top individuals with disabilities to buy period. This decline in out-of-network of-network.7 controlled for enrollees’ health status, refers to unexpected “balance billing,” insulin, two commonly used drugs that for drugs that are old and to consider price when distributing is uninsured or has low-quality of mind for American voters. Forty- Medicaid coverage if their income or coverage leaves more patients exposed to Dealing with the Medicaid costs less than private when the provider sends a bill directly to have been on the market for decades. commonly used but effective. a prescription to the patient. This prescription painkiller insurance, they will have no protection one percent of national voters in exit assets would otherwise make them unexpected charges. 5 Scenario 2: A patient requires addiction epidemic 39% 46% 51% insurance. Similarly, Medicaid’s per the patient for the balance of the amount There are several reasons that means that even when a drug may from the “sticker price” of the health care polls identified health care as the single ineligible for Medicaid coverage.4 immediate emergency medical care enrollee costs have grown more slowly above and beyond what insurance covers While all these examples illustrate a common, long-available drugs can offer a very limited benefit or when Repealing the 2010 21% 32% 63% they use. most important issue facing the nation, COMMON SURPRISE BILLING and is transported and, in many cases, health care law 10 1 pricing problem, there are actually several an equally effective and less costly outpacing both immigration and the MEDICAID BUY-IN IS AN compared to other payers. and what was expected by the patient. be expensive or suddenly spike in APPEALING OPTION FOR SCENARIOS admitted to a hospital outside of his or different dynamics at work in each case, option is available, patients may Decreasing the role of How are People Covered in the US? economy.1 With a divided federal price. Sometimes, as in the case the federal government in 26% 34% 50% CONSUMERS Recent news reports have helped her insurance network. spanning business practices, health policy, not be aware they have a choice, health care government, meaningful federal action Medicaid Buy-in proposals can be These surprise bills have emerged as of shortages, a mismatch between Medicaid is no longer just a niche highlight and illustrate common surprise and clinical implications.2 At the root allowing pharmaceutical companies to expand coverage, including significant a growing complaint-- and a source of supply and demand can prompt Decreasing how much the Marketplace program for certain populations. It is a structured to help state policymakers  Uninsured fear-- for many Americans. One study, bill scenarios. A teacher in Texas suffered a heart of the issue in each case, however, is the a significant price hike. More to maintain or raise prices without federal government spends 31% 35% 43% 7% progress to modify the Affordable Care familiar source of affordable health care achieve a range of goals and address on health care over time 9% which examined one insurer’s data from attack and was transported to a so-called “list price” of the drug that is set often, however, pharmaceutical concern about the usual impact of Act or action on the various proposals for many families and communities, varying priorities. January 2014 through September 2015, Scenario 1: A patient seeks care at a hospital that did not participate by the manufacturer. While that price can companies increase prices simply competition. that would allow people to purchase providing health care coverage to 19% Kaiser Health Tracking Poll 2 found that 22% of emergency department facility that is in their insurance network, in the network of the insurance become dramatically skewed through the because it is profitable.3 There are Other Public Medicare coverage , is highly unlikely 5 Medicaid has 2% of the U.S. population. Increasing choice and competition: 2 but is treated by a provider that is outside plan offered by his school district. cases involved out-of-network care. distribution chain because of discounts, many loopholes that allow drug  Extremely high prices for Medicaid Employer for the next two years. In the near- evolved to fit the diverse needs of Americans receive health care coverage from many 50% In 2019, 35% of counties will have Another study, which examined a of their network, like an out-of-network His insurance company paid rebates, and insurance coverage, the list manufacturers to monopolize the new and effective treatments. 20% term, states will be the testing grounds different enrollees, including children, only one issuer offering coverage on anesthesiologist working at a hospital in a approximately $55,000 for 4 days price is always at the center of those different sources for developing new ways to expand parents, those receiving long-term care, collection of insurers, found that in 2014, market for certain drugs: gaming Periodically, new drugs come to the Marketplace.11 Creating a way patient’s network. of inpatient care, leaving him with a insurance coverage. Some state leaders people with disabilities and childless 20% of hospital inpatient admissions calculations, and has a direct relationship of special programs designed to market that have the potential to for consumers to purchase Medicaid led to a surprise bill.3 A Kaiser Family balance bill of $108,951.8 About 1/3 of the population is covered through Medicare and Medicaid— are already looking for ways to improve adults. Medicaid provides comprehensive to the price paid by many consumers. incentivize the development of dramatically improve treatment Medicare programs that offer insurance to seniors, people with disabilities and health care affordability and choice. coverage could generate more Foundation survey found that 38 percent  In emergency situations, patients Consequently, the single most impactful treatments for rare disease, “pay-for- options for a given disease, as in 14% coverage of benefits tailored to different certain medical conditions, and families and individuals who qualify Because Medicaid is primarily state-run, it competition in areas with few issuers, of people are very worried about being have no time to research whether Scenario 3: A patient is transported in action policymakers can take on the issue delay” tactics to prevent competitors the case of CAR T-cell therapies groups of enrollees in the program with because of their income. provides an option for states to explore in minimal cost sharing.6 And Medicaid giving consumers more choices, and able to afford unexpected medical bills the specialist treating them in the an air or ground ambulance that does not order to make health care coverage more beneficiaries are generally satisfied with reducing the risk of bare counties with no for themselves and their families, with an emergency department participates participate in their insurance network. 1 https://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-march-2018-prescription-drug-pricing-medicare-for-all-proposals/ While most of the recent health care debate has focused on the Affordable affordable. their care, with Medicaid enrollees in a issuers offering coverage. additional 29 percent being somewhat in their insurance network. Scott One study found that more than half of 2 https://ldi.upenn.edu/healthpolicysense/what%E2%80%99s-story-drug-prices worried.4 Kohan was transported to a Texas ambulance transport in 2014 occurred 3 http://www.latimes.com/business/hiltzik/la-fi-hiltzik-drug-prices-20181008-story.html Care Act, only 7% of people purchase insurance through the Marketplaces created by the law—a number that’s dwarfed by the almost 50% of 1 1 Prescription Drug Prices: Problems, Solutions, and What States Can Do 1 “Surprise” Medical Bills: States Opportunities to Protect Patients Americans covered by insurance offered through their employer.

Medicaid Buy-In: “Surprise” Medical Prescription Drug Health Policy State of Play Bills: State Prices: Problems, Resource Guide Many states Opportunities to Solutions, and What The Health Care are considering Protect Patients States Can Do Policy Resource Guide Medicaid buy-in as “Surprise” medical Prescription drug serves as a resource a potential step to bills have emerged as pricing is an issue that for current and control insurance a growing complaint is important on both potential policymakers, costs, stabilize their and source of fear sides of the aisle. This both federal and insurance markets and for many Americans. brief identifies drivers in our home state provide consumers United States of of rising prescription of Minnesota, to with more options. Care’s brief explores drug costs and familiarize themselves Our brief provides how states can take reviews ways that with the evolving an overview of how action to protect states can address health care landscape. Medicaid buy-in patients from these them. works, why it is an unexpected health attractive policy option care costs. for states, and current state movement on this issue. “Policymakers, especially when promising seemingly easy solutions that they claim will make health care more affordable for everyone, should think first about the conversations that go on around kitchen tables, and whether their proposed solutions will help the people who need it.” — KRISTIN WIKELIUS, SENIOR POLICY DIRECTOR, UNITED STATES OF CARE

10 UNITED STATES OF CARE | 2018 ANNUAL REPORT 2019 State Outlook: 5 Opportunities for Medicaid Buy-in: Crossing Health Bipartisan Collaboration Care’s Political Divide To: Interested Parties To: Interested Parties From: Emily Barson, Executive Director From: Tom Kise, Senior Director of Public Affairs Date: January 10, 2019 Re: Polling on Medicaid Buy-in - New Mexico and National Date: January 29, 2018

Key Highlights Since our founding last year, USofC has for many families and communities, Key Takeaways Incoming lawmakers can collaborate in been talking with policymakers, advocates, providing health care coverage to 19% of  Medicaid Buy-in is supported by To date, the idea of Medicaid Buy-in, When we look at our findings around five important areas: and health care leaders across the country the U.S. population.6 A recent poll found the majority of voters regardless of or the idea that individuals can have Medicaid Buy-in and place the issue in to learn more about state-level health that 51% of respondents are in favor of party. the option to pay into a system that is context with other publicly released  Making insurance more affordable reform efforts. We strategically spoke a Medicaid Buy-in plan, with only 9.6%  The cost of health care continues to building on their state’s current Medicaid polling on health care writ large, we have  Addressing skyrocketing prescription with leaders from more than 20 politically opposed. Because Medicaid is primarily be a driving concern for voters infrastructure, has received a broad level found that Democrat and Republican drug prices blue, red and purple states, in all regions state-run, it provides an option for states  Voters value predictability and of support regardless of party. voters share one core concern and want  Protecting consumers from surprise of the country. The good news is that to explore to make health care coverage security when comes to healthcare; their elected officials to solve for it - cost. out-of-pocket costs there are many areas ripe for progress and more affordable, and states can design a policies that address these values, Nationally, we found that 78 percent of  Buy-in that meets their unique needs. Addressing non-medical drivers of bipartisan cooperation -- regardless of like Medicaid Buy-in, will gain Americans supported the idea and said Earlier this month, Colorado’s House health it should be a priority for their state where you live, or whether Republicans traction with voters. Health and Insurance Committee passed  Enforcing mental health parity ADDRESSING SKYROCKETING governments. This was reinforced by a or Democrats hold elected office in your  Because Medicaid Buy-in is a their version of a Buy-in bill out of PRESCRIPTION DRUG PRICES recent Kaiser Family Foundation poll committee with a bipartisan vote. This state. relatively new concept, it is not As the heated political rhetoric of election States are not waiting for Congress or that similarly found that 75 percent currently a hyper-partisan issue. demonstrates another positive trend that season recedes, it’s time to look ahead federal officials to take action to address of Americans view a Medicaid Buy-in FIVE OPPORTUNITIES FOR has continued to hold true - the idea of at how newly elected leaders who are concerns about prescription drug costs. favorably. BIPARTISAN COLLABORATION In late 2018, United States of Care Medicaid Buy-in has largely remained off entering office can deliver on their Our poll makes it clear that Americans Based on our listening and outreach, commissioned public opinion research in of the “list” of litmus test issues that too promises and respond to the voters’ desire have demanded it--91% of those surveyed Polling in New Mexico, the state leading USofC has identified five areas in which New Mexico and nationally focusing on often sidetrack the legislative process. for meaningful action on health care. said it was a top or significant priority for the charge for buy-in legislation, found incoming lawmakers should seize the the idea of Medicaid Buy-in. This memo their state legislature to take up. During very similar results. The concept of This fact should be encouraging to opportunity to work together and make aggregates and analyzes our learnings In last year’s midterm election, people last year’s state legislative sessions, buying into the states Medicaid program lawmakers and constituents alike as this meaningful progress while Washington from three separate pieces of research, voted for action on health care across 42 states (84 percent) introduced 163 was supported by 74 percent of New option is explored in statehouses across DC prepares for the gridlock that often and places them in context within the the country and up and down the ballot. separate bills to address drug prices in Mexicans once they knew about the idea. the country. accompanies divided government. larger ongoing policy debate. Forty-one percent of national voters in some way.7 While many of the most exit polls1 identified health care as the MAKING INSURANCE MORE impactful policy interventions related single most important issue facing the KEY NATIONAL LEARNINGS AFFORDABLE to drug prices would require federal nation, outpacing both immigration and  Health care should be affordable. Whether Republican or Democrat, people action, there are several actions states can the economy. The same poll found that 88 percent of voters think that they agree that health care costs too much.2 take to achieve important goals, such as 69% of voters believe that the American and their neighbors should have Policymakers have already come together addressing underlying prices, controlling health care system needs major changes. an affordable, regular source of --often across party lines-- in seven states3 state spending on drugs, and providing to create reinsurance programs that are relief to consumers.8 health care for themselves and their The changes that people are seeking helping to reduce premium costs and family. Support by party - 95 percent do not have to be the source of political other states can consider taking similar PROTECTING CONSUMERS FROM of Democrats and 82 percent of rancor. The election results demonstrate action. SURPRISE OUT-OF-POCKET Republicans. what we at United States of Care (USofC) HEALTH CARE COSTS  Medicaid Buy-in is an important strongly believe: pursuing access to With individual market premiums So-called surprise medical bills are a next step. 78 percent of voters affordable health care does not need to holding relatively stable for 20194, states growing source of frustration and anxiety think Medicaid Buy-in is a potential divide people based on their political are looking to move beyond near-term for Americans. The term “surprise important next step. Support by beliefs. Traditional partisan lines are crises to explore innovative new options bills” is used in different ways, but party - 89 percent of Democrats and starting to blur, with strong majorities to make health coverage more affordable. most commonly refers to unexpected 76 percent of Republicans. in 3 traditionally red states voting to Fourteen states are in various stages of “balance billing,” when the provider  Voters think state government is expand Medicaid, and voters in a diverse exploring Medicaid buy-in proposals, sends a bill directly to the patient for the best suited to take on Medicaid set of states (Ohio, Maine, Kansas, and which, in general, would allow some balance of the amount above and beyond Buy-in. 56 percent of voters think Wisconsin) electing governors who also individuals to purchase Medicaid or what insurance covers and what was that their state government is best 5 support Medicaid expansion. Medicaid-like coverage. Medicaid is a expected by the patient. A Kaiser Family suited to take this next step and (United States of Care, six focus groups among registered voters in Albuquerque and Santa Fe, familiar source of affordable health care Foundation survey found that 38 percent address the issue. Support by party October 17-18, 2018.) - 55 percent of Democrats and 58 1 percent of Republicans. 1

Interested Parties 2019 State Outlook: Medicaid Buy- Memo: 2019 5 Opportunities In: Crossing Potential State for Bipartisan Healthcare’s Political Policy Trends Collaboration Divide Based on our As the country faces In late 2018, United outreach and on- a divided government States of Care the-ground learning, in DC, United States commissioned public our memo examines of Care has identified opinion research in opportunities for five actionable health New Mexico—and states to take care issues that are nationally—focused on meaningful action to ripe for progress and the idea of Medicaid address health care bipartisan cooperation buy-in. This memo challenges. United at the state level. aggregates and States of Care is analyzes our learnings working to identify from this research and fill gaps to help and places them in states make progress. context within the larger ongoing policy debate. United States of Care is proud to partner with Penn’s Leonard Davis Institute of Health Economics to provide resources and actionable approaches “If we can get to policymakers, based on analysis of evidence, and best practices. Americans to stop November 2018 November February 2018 February having to worry about WHAT IS “AFFORDABLE” HEALTH CARE? STATE EFFORTS TO CLOSE A review of concepts to guide policymakers THE HEALTH COVERAGE GAP

Although the “affordability” of health care is a common concern, the term is rarely defined. Fundamentally, affordability is a function of income, spending, and judgments about the value of goods and services for their This review examines prominent state efforts to expand health coverage to the remaining uninsured. It analyzes price. This brief considers affordability as an economic concept, as a kitchen-table budget issue for individuals and compares efforts in Massachusetts, Vermont, Colorado, California, and Nevada and highlights insights and and families, and as a threshold in current policy. It reviews a range of measures that capture the cost burden for themes that emerge. It explores the context and climate for reform within the state, stakeholder involvement, affording health individuals and families with different forms of coverage, in different financial circumstances, and with different political coalitions, financing, and possible opposition. As such, it serves as a case study in how different states health concerns. build, or fail to build, the popular and political will towards health care coverage for all residents. This is the first in By any measure, many Americans are experiencing significant problems due to health care costs, whether through a series of reports that will monitor and analyze developments at the state level to expand coverage and improve high deductibles that discourage them from seeking health care, uninsurance or gaps in insurance benefits, or access to care. the less-noticed erosion of wages due to rising health insurance premiums. To transform affordability from an aspirational goal to a policy aim, policymakers will need to consider a number of key issues, including: the cost of care versus the cost of insurance, how to fairly distribute costs, consumers’ most salient affordability concerns, the There is a health coverage gap in the United States, with nearly policies to get us there. Further federal movement in that direction root causes of financial barriers to care, and the differential impact of various policies on stakeholders. 28 million individuals lacking health insurance coverage. While is unlikely in the immediate future, given the recent gridlock of the health insurance is not a guarantee of affordable health care or federal government. However, there has been activity at the state better health outcomes, recent evidence indicates that expanding level toward this goal in recent years. coverage increases patients’ access to primary care, preventive care, This review focuses on prominent state efforts that have, or had, as care, we can move chronic illness treatment, medications, and surgery. State and federal governments have grappled with their role in ensuring coverage, their primary goal to close the coverage gap, and highlights insights The affordability of health care is a bipartisan issue and ongoing in different financial circumstances, and with different health concerns. and themes that emerge. Other states have targeted important and concern for most Americans.1 It is no accident that the short title of We look at the impact of the Affordable Care Act (ACA) on attempting to close the coverage gap with a mix of public and/or private programs. relevant issues such as controlling health care costs, stabilizing private the 2010 federal reform law was the Patient Protection and Affordable measures of affordability, and identify key issues for policymakers to markets, improving choice, and increasing price transparency, all of Care Act, signaling the goals of protecting patients from undue consider as they address health care affordability for individuals and The Affordable Care Act (ACA) of 2010 was the most recent which may help to expand coverage, but these efforts are beyond the financial burden and expanding access to affordable care through families. federal attempt to fill gaps in health coverage, and it made scope of this review. broader insurance coverage. There is near unanimity on the goal of significant progress in reducing the uninsured rate. It is notable that affordable health care, but little agreement on how to define and as a compromise agreement, the ACA focused on incremental Overall, this review serves as a case study in how different states measure affordability, much less how to operationalize a definition into HEALTH CARE “AFFORDABILITY:” improvements rather than large-scale overhaul, particularly in the build, or fail to build, the popular and political will towards health care workable policy. coverage for all residents. What might we learn across the experience OFTEN INVOKED, RARELY DEFINED expansion of Medicaid and changes to the individual insurance market. Even if the ACA had been implemented as originally written, of very different states, proposing very different solutions? We In this brief, we consider health care affordability as an economic Unlike most economic measures, affordability is essentially a explore the importance of the current coverage gap within the state, concept, as a kitchen-table budget issue for individuals and families, the Congressional Budget Office (CBO) projected that it would sentiment. It involves a qualitative ability and willingness to pay—an have left 23 million nonelderly people uninsured in 2019. building public will, stakeholder involvement, political coalitions, and as a threshold in current policy. We review a range of measures to interaction of spending, income, and judgments about the value financing, and possible opposition. capture the cost burden for people with different forms of coverage, of something relative to its price. But health care differs from other Overall, the goal of expanding coverage to the remaining uninsured the country to start enjoys general public support, but there is little consensus around

LDI.UPENN.EDU | @PENNLDI | UNITEDSTATESOFCARE.ORG | @USOFCARE

LDI.UPENN.EDU | @PENNLDI | UNITEDSTATESOFCARE.ORG | @USOFCARE talking about how we What is Affordable State Efforts to Close Health Care? the Health Coverage A Review of Gap can make the country Concepts to Guide Our joint review of Policymakers state efforts to close This joint brief focuses the coverage gap healthier.” on affordability as an examines how states economic concept, as build, or fail to build, — ANDY SLAVITT, a kitchen-table budget the popular and UNITED STATES OF CARE BOARD CHAIR issue for individuals political will towards and families, and as health care coverage a threshold in current for all residents. policy. UNITED STATES OF CARE | 2018 ANNUAL REPORT 11 PUBLIC OPINION RESEARCH

In our inaugural year, United States of Care focused much of our public opinion research on understanding national knowledge levels and attitudes regarding Medicaid buy-in, and gathering evidence to support our premise that Americans agree more than they disagree when it comes to their health care.

As United States of Care moves into the next phase of our public opinion research, we will continue to focus on both of these areas of study. We also plan to use public opinion research as a tactical tool to help educate policymakers about the choices they are facing.

Understanding Medicaid Buy-In Medicaid buy-in is an innovative approach that would allow individuals to purchase state-sponsored coverage similar to Medicaid. Policies could be tailored to suit the unique needs of different states.

78% 74%

Our research found Medicaid buy-in would of all Americans Medicaid buy-in is that the complexity address these issues support Medicaid supported by 74% of and cost of accessing by expanding access buy-in and believe it New Mexicans who health care feels like to a health care should be a priority for were informed about a threat to individual program that has a state governments the idea security proven track-record of containing costs

Big Picture: The FEELING HELPLESS complexity and cost “The word is not gratitude; it’s fear.” of accessing health —DEMOCRAT care feels like a threat to “I am not smart enough” Limited access Financial concerns “You need a tutor to get you “[Health care] is inaccessible.” “It’s anxiety-producing; it’s individual through it.” —DEMOCRAT expensive.” security —INDEPENDENT —REPUBLICAN

Can’t navigate Don’t understand Can’t get Health care is Health care costs the system coverage appointments with too expensive are unpredictable “I don’t have a “It’s very their doctors “There’s a lot of “Co-pays, good picture of the complicated.” “No doctor or people who can’t deductibles...we system.” —INDEPENDENT dermatologist afford health care.” never know from —DEMOCRAT would take us.” —INDEPENDENT year to year.” —REPUBLICAN —REPUBLICAN

12 UNITED STATES OF CARE | 2018 ANNUAL REPORT “Regardless of the politics of the moment, people want to know that if they are sick or injured they can see a doctor and afford their treatment. This research confirms that voters value predictability and security when it comes to health care and that they support policies, like Medicaid buy-in, that increase access to affordable care.”

— DR. J. MARIO MOLINA, UNITED STATES OF CARE FOUNDER’S COUNCIL MEMBER AND PRESIDENT OF GOLDEN SHORE MEDICAL GROUP

Finding Common Ground Regardless of party, Americans agree that health care costs are too high and should be a priority for states.

93%

of registered 81% of 87% of 88% of voters said that Republicans and Republicans and Republicans and health care was a 85% of Democrats 95% of Democrats 94% of Democrats very or somewhat agree that the rated affordable agree that surprise important issue to cost of quality prescription medical bills them in how they medical care is drugs as a top or should be a top or voted in 2018 a big problem, significant priority significant priority suggesting for their state for their state a possibility legislatures legislatures for bipartisan cooperation

United States of Care’s Public Opinion Research States should make health care coverage more affordable by allowing every resident of their state the opportunity to buy insurance through their state’s Medicaid program.

How much of a priority Who is best suited to enact a should Medicaid buy-in be? Medicaid buy-in program? 78%

45%

22% 56% 33% 16% 37% 6% 16% Priority Not A Priority Your State Congress The Government President

significant priority top priority not a very high priority not a priority at all

UNITED STATES OF CARE | 2018 ANNUAL REPORT 13 DRIVING THE HEALTH CARE CONVERSATION

Focus on states for health care solutions this midterm election (10/02/18, THE HILL)

Statewide View: Tough days for those in pain— Minnesota must improve its mental health parity (11/02/18, DULUTH NEWS TRIBUNE)

El próximo paso para el cuidado de salud: crear un movimiento (02/06/18, LA OPINIÓN)

I’m helping found a national health care movement. Let me tell you why. (02/06/18, FORBES)

Our broken health care politics are hurting instead of helping Americans (02/06/18, USA TODAY)

“Tangible action to improve health care for all Americans is already happening at the state level, where politics is less polarized and closer to the people these policies affect.”

— EMILY BARSON, EXECUTIVE DIRECTOR AND TOM KISE, SENIOR DIRECTOR OF PUBLIC AFFAIRS

14 UNITED STATES OF CARE | 2018 ANNUAL REPORT UNITED STATES OF CARE IN THE NEWS

Forget ‘Repeal and Replace.’ The One Issue Unifying Americans Is Affordable Health Care Executive Director Emily Barson and (HALEY SWEETLAND EDWARDS, 11/1/18, TIME) Senior Director of Public Affairs Tom Kise joined Paul Orgel of C-Span’s Washington Journal (10/15/18)

The States Tackle Health Care Reform The Health 202: ‘Medicare for all’ is the dream. ‘Medicaid for more’ could be the reality (SUSAN MILLIGAN, 8/10/18, US NEWS AND WORLD REPORTS) (COLBY ITKOWITZ, 8/2/18 WASHINGTON POST)

Healthcare after the 2018 midterm election: As ‘Troubling and shocking’: Americans are control shifts, certainty settles in increasingly crowdfunding medical costs (11/18, PWC) (ADRIANA BELMONTE, 8/18/18, YAHOO FINANCE)

Medicaid ‘Buy-In’ Could Be a New Health Care ‘Strange Bedfellows? Group Unites Option for the Uninsured Old Foes in Hunt for Health Fix (MICHAEL OLLOVE, 1/10/19, STATELINE) (ZACHARY TRACER, 2/6/18, BLOOMBERG)

New Mexico Could Become CMS’ Boehler, NC Health Chief Cohen First State To Pass Medicaid Buy-In Talk Strategies at United States of Care Panel (ARIEL COHEN, 10/16/18, INSIDE HEALTH POLICY) (ALLISON INSERRO, 12/03/18, AMERICAN JOURNAL OF MANAGED CARE)

UNITED STATES OF CARE | 2018 ANNUAL REPORT 15 When United States of Care launched on February 6, 2018 it added a much-needed voice to the health care conversation, highlighting bipartisan, state-driven, common sense solutions. Throughout our first year, United States of Care’s activities helped re-energize media coverage around Medicaid buy-in and other pathways to accessible, affordable care.

The Launch of United States of Care Was a Major Topic of Health Care Coverage During Launch Week

Topics US of Care Launch 39

ACA 39

Single Payer 19

Medicaid Expansion 18 & Reforms Budget Deal 11

Industry News 9

Access to Care 2 News Stories

Coverage of United States of Care Launch Was Overwhelmingly Positive

Nature of Coverage Positive Neutral Negative

US of Care Launch 64% 23% 13%

16 UNITED STATES OF CARE | 2018 ANNUAL REPORT United States of Care Recharged Media Coverage of Medicaid Buy-In

14 Aug. 8th, 2018: United States of Care releases 12 “State Policy Trends” memo, highlighting Medicaid buy-in

10

8

6

4 Nov. 29th, 2018: US of Care hosts its Medicaid buy-in press call. 2

Number of Articles Mentioning Medicaid Buy-in 0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

months

“As states look for opportunities to control insurance costs, stabilize their insurance markets and provide consumers with more options, Medicaid buy-in is emerging as a potential solution under consideration in many states. Medicaid buy-in proposals can be structured to help state policymakers achieve a range of goals and address varying priorities.”

— KRISTIN WIKELIUS, SENIOR POLICY DIRECTOR AND ALLISON O’TOOLE, SENIOR DIRECTOR OF STATE AFFAIRS

UNITED STATES OF CARE | 2018 ANNUAL REPORT 17 UNITED STATES OF CARE INAUGURAL CONVENING THE PATH AHEAD: A ROAD MAP FOR AMERICAN HEALTH CARE

“Government should make it easier, not harder, to get access to affordable health care. As the mother of a child who has had complex medical needs since she was born, I’ve seen first- hand how difficult it can be to get access to the health services my daughter needed to stay alive. United States of Care will work to deliver all Americans a better system.” —NATALIE WEAVER

United States of Care’s inaugural convening took place on December 3, 2018. The Path Ahead: A Road Map for American Health Care, brought together more than 100 patients, advocates, policymakers, influencers, and researchers from across the country to discuss the future of health care in the United States. The day-long event featured panel discussions exploring a wide variety of topics, ranging from public opinion, to innovative work currently underway in states, to long-term prospects for federal reform. The convening was a wonderful opportunity to reflect on our first year as an organization, and to strategize with attendees about priorities moving forward.

View the livestream of the convening View photos from the event Hear from our Founder’s Council

18 UNITED STATES OF CARE | 2018 ANNUAL REPORT STAFF

In our first year, United States of Care has grown to include 13 full-time staff members, who share a commitment to ensuring that Americans have access to quality, affordable health care. We look forward to continuing to expand our Minnesota and DC offices in the coming year.

FELLOWS

The United States of Care Fellowship Program aims to connect health care experts with policymakers and Jason Helgerson advocates. As United States of Care’s inaugural policy Former Medicaid Director, fellows, Jason Helgerson and John B. McCarthy leverage New York and Wisconsin their specialized knowledge and on the ground experience to help United States of Care develop and refine policies that ensure a regular source of care and better health for more Americans. Helgerson and McCarthy are two well-regarded leaders with deep expertise in state-based health policy, having served as Medicaid directors for Governors Cuomo of New York and Kasich of Ohio, respectively. John B. McCarthy Former Medicaid Director, Ohio and DC

UNITED STATES OF CARE | 2018 ANNUAL REPORT 19 BOARD OF DIRECTORS “A new national dialogue on health care should reflect this reality: health care is personal, it’s tangible, it’s human. It’s an issue that deserves solutions, not slogans.”

—WILLIAM FRIST OP-ED, “I’M HELPING FOUND A NATIONAL HEALTH CARE MOVEMENT. LET ME TELL YOU WHY,” FORBES, 2/6/18 BOARD CHAIR

Andy Slavitt Jim Douglas Rhonda Medows, M.D. Steve Beshear Former Former Executive Vice Former Governor of Acting Administrator Governor of Vermont President, Kentucky of the Centers Providence for Medicare and St. Joseph Health Medicaid Services

Kristie Canegallo Dave Durenberger William Frist, M.D. Vice President of Trust Former Former and Safety, Google; United States Senator United States Senate Former Deputy White from Minnesota Majority Leader House Chief of Staff from Tennessee to President Obama

“Folks in your states, in your district, actually want bipartisanship. Good work builds on good work. I believe that we can push back on the torrent of partisanship by coming together.” —KRISTIE CANEGALLO, UNITED STATES OF CARE INAUGURAL CONVENING

20 UNITED STATES OF CARE | 2018 ANNUAL REPORT FOUNDER’S COUNCIL

Drew Altman—President & CEO, Charles Grim, D.D.S.—Executive Director, Cherokee Peter Orszag—Former Director of the Office of Kaiser Family Foundation Nation Health Services, Former Director, Indian Management and Budget under President Peter B. Bach, M.D.—Director, Health Service under President George W. Bush Obama; Global Co-Head of Healthcare Memorial Sloan Kettering’s Center for Jim Haveman—Former Director, Michigan at Lazard Health Policy and Outcomes Department of Community Health Todd Park—Former Chief Technology Officer of the Max Baucus—Former U.S. Senator from Montana Sandra Hernández, M.D.—President & CEO, United States; Entrepreneur Melanie Bella—Former Director of the CMS California Health Care Foundation Peter W.T. Pisters, M.D.—President, The University of Medicare-Medicaid Coordination Office; Chief of Rod Hochman, M.D. —President & CEO, Texas MD Anderson Cancer Center New Business and Policy, Cityblock Health Providence St. Joseph Health Ron Pollack—Former Founding Executive Director, Donald M. Berwick, M.D.—President Emeritus Douglas Holtz-Eakin—President, American Action now Chair Emeritus, of Families USA and Senior Fellow, Institute for Healthcare Forum; Former Director of the Congressional Thomas M. Priselac—President & CEO, Cedars-Sinai Improvement; former Administrator, Centers Budget Office, Chief Economist to President Health System for Medicare & Medicaid Services under George W. Bush, and Commissioner on Medicare Judy Rich, R.N.—President & CEO, TMC Healthcare President Obama Payment Advisory Commission Andy Richter—Actor and Activist Tom Betlach—Former Director of the Arizona Health Elena Hung—Parent Advocate, President & Steven Safyer, M.D.—President & CEO, Care Cost Containment System Co-founder of Little Lobbyists Montefiore Medicine David Brailer, M.D., PhD.—Chairman, Health Chris Jennings—Senior Health Care Advisor to Ninfa Saunders—President & CEO, Evolution; National Coordinator for Health Presidents Obama and Clinton Navicent Health Information Technology under Dean Kamen—Inventor and Philanthropist Mina Schultz, M.P.H.—Patient, Advocate, and President George W. Bush Bob Kocher, M.D.—Partner, Venrock; former Outreach Specialist with GetCoveredNYC Lanhee Chen—David And Diane Steffy Research Special Assistant to the President for Lan Sena—Community Leader, Health Care Fellow, Hoover Institution; Director of Domestic Healthcare and Economic Policy on the Policy Studies In Public Policy, Stanford University National Economic Council Advocate, and Cancer Patient Esther Choo, M.D., M.P.H.—Emergency Medicine Bill Kramer, M.B.A.—Executive Director for Meena Seshamani, M.D., PhD.—Director of Clinical Physician and Associate Professor, Oregon Health Policy, Pacific Business Group on Health Performance Improvement, MedStar Health; Health & Science University Sarah Krevans—President & CEO, Sutter Health Former Director, Office of Health Reform at the Rebecca Cokley—Former Executive Director Leonard Lance—Former U.S. Representative Department of Health and Human Services of The National Council On Disability; from New Jersey Josh Sharfstein, M.D.—Vice Dean for Public Health Director for Disability Policy, Center For Curtis Lane—Chair, Executive Advisory Board of the Practice and Community Engagement at Johns American Progress Leonard Davis Institute of Health Economics; Hopkins Bloomberg School of Public Health Patrick Conway, M.D.—Former Deputy Investor and Entrepreneur Randi Mayem Singer—Screenwriter, Producer, and Administrator, Centers For Medicare and Margaret Laws—President & CEO, Hopelab Showrunner; Alzheimer’s Advocate Medicaid Services, President & CEO of Blue Cross Mike Leavitt—Former Governor of Utah and David Smith—Founder, Third Horizon Strategies North Carolina Secretary of the US Department of Health and Mark Smith, M.D.—Founding President & CEO, Matthew Cortland—Lawyer, Author, Chronically-Ill Human Services California Health Care Foundation Patient, Patient Advocate Alan Levine—Executive Chairman, President & CEO, Tony Tersigni—President & CEO, Ascension Molly Coye, M.D.—Former Commissioner of Ballad Health David Torchiana—President & CEO, Health for the state of New Jersey and Abel Maldonado—California’s 47th Partners Healthcare Director of the California State Department of Lieutenant Governor Nick Turkal—President & CEO, Health Services Beverly Malone, PhD., R.N.—CEO, National League Advocate Aurora Health Mark Cuban—Investor and Entrepreneur for Nursing; Past President, American Nurses Bernard Tyson—Chairman & CEO, Tom Daschle—Former U.S. Senate Majority Leader Association Kaiser Permanente from South Dakota Abner Mason—CEO, ConsejoSano; Member of Vikki Wachino—Principal, Viaduct Consulting, LLC; Pete Davidson—Comedian and Mental President George W. Bush’s Advisory Council former Deputy Administrator and Director of the Health Advocate on HIV/AIDS Center for Medicaid and CHIP Services at CMS Lloyd Dean—President & CEO, Dignity Health Mark McClellan, M.D., PhD.—Former Administrator Natalie Weaver—Parent Advocate, Co-founder of Charlie Dent—Former U.S. Representative of CMS and Commissioner of the FDA, Director of Advocates for Medically Fragile Kids NC from Pennsylvania the Duke-Margolis Center for Health Policy Jim Weinstein, D.O.—Former CEO & Jon Favreau—Former Head Speechwriter, President Chirlane McCray—First Lady of New York City, President of Dartmouth-Hitchcock and Obama; Founder of Crooked Media and Co-host Founder of Cities Thrive Dartmouth-Hitchcock Health of Pod Save America Benjamin F. Miller, Psy.D.—Chief Strategy Officer, Gary Wertish—President, Minnesota Trevor Fetter—Sr. Lecturer, Harvard Business School; Well Being Trust Former Chairman & CEO, Tenet Healthcare Corp. J. Mario Molina, M.D.—President of Golden Shore Farmers Union Atul Gawande, M.D.—Surgeon, Public Health Medical Group and former CEO of Molina Penny Wheeler, M.D.—President & CEO, Researcher, Writer; CEO, Amazon, JPMorgan Healthcare Allina Health Chase, Berkshire Hathaway nonprofit health Ian Morrison—Author, Consultant, and Bradley Whitford—Actor and Activist venture Healthcare Futurist Gail Wilensky—Former Administrator of the Health Gabby Giffords—Former Congresswoman Cecilia Muñoz—Former Director of the White House Care Financing Administration under President from Arizona Domestic Policy Council under President Obama; George H.W. Bush Rick Gilfillan, M.D.—CEO, Trinity Health VP, New America Cindy Zeldin—Consumer Advocate, Darin Gordon—Former Director of Tennessee Janice Nevin, M.D., M.P.H.—President & CEO, Former Executive Director of Georgians for a Medicaid - TennCare Christiana Care Health System Healthy Future

UNITED STATES OF CARE | 2018 ANNUAL REPORT 21 SUPPORT SPECIAL THANKS TO ALL THOSE WHO MADE OUR FIRST YEAR POSSIBLE

United States of Care is supported by individuals and non-profit health care organizations, including not-for-profit charity hospitals and foundations. We do not accept funding from trade associations, PACs, insurance companies, or for-profit corporations.

It is only with the investment and generosity of our partners that we are able to make progress toward our mission. Thank you to our supporters, who have stood up for the millions of Americans without access to quality, affordable health care.

Sources of Support­—Inception Through 2018 Non-Profit Health Care Organizations

With special appreciation to our United States of Care Hospital Affinity Group members, who 31% provide invaluable support and Non-Profit guidance to our work Health Care Organizations 65% Advocate Aurora Health Individual Allina Health Supporters Ascension Ballad Health Cedars-Sinai Health System Christiana Care Health System 4% Dignity Health Foundations MD Anderson Cancer Center Montefiore Health System Partners HealthCare Providence St. Joseph Health Sutter Health Trinity Health

Partners

22 UNITED STATES OF CARE | 2018 ANNUAL REPORT UNITED STATES OF CARE | 2018 ANNUAL REPORT 23 unitedstatesofcare.org @usofcare