Health policy specialist Colleen Becker delivered a crash course Thursday on actions by state legislatures across the United States to mitigate the cost of health care that might be adapted by Kansas lawmakers looking for big answers.

Becker, who works for the nonpartisan National Conferences of State Legislatures, said Louisiana, Maine and Minnesota moved this year to block consumer copayments higher than the full cost of a drug. The move was aimed at middlemen companies handling drug claims for insurance companies who claw back the extra dollars from pharmacists.

She told the House and Senate interim committee on insurance that Utah began offering incentives to state employees willing to travel to Mexico to buy less expensive medicines.

Colorado mandated hospitals report uncompensated care to the state. Nevada placed a price cap on the cost of diabetes drugs. Oklahoma was the first state to link performance standards to four drugs with potential to decrease hospitalizations.

"NCSL regularly tracks prescription drugs," Becker said. "In 2019 alone, we had over 890 bills filed across all 50 states and D.C. With those kinds of numbers, it's easy to see that the momentum is growing around states related to prescription drug pricing."

Members of the committee were eager to pursue lines of questioning about whether the Affordable Care Act, which expanded Medicaid eligibility for millions of people in the United States, was a force in rising health costs.

"We didn't solve a problem," said Sen. Rob Olson, an Olathe Republican who chairs the special committee. "We created a new one."

He also said Kansans were being driven into bankruptcy by rising health insurance deductibles and indicated the committee would be searching for avenues to moderate that trend.

Rep. Elizabeth Bishop, D-Wichita, said the state ought to mandate greater transparency in operations of pharmacy benefits managers, or PBMs, who negotiate with drug makers on which medicines make insurance plans’ lists and how much insurers’ plans pay for them. PBMs also require manufacturers who supply the product and the pharmacies who sell to patients sign nondisclosure agreements.

"It is difficult to tell what is affecting price if you can't see what the middleman is taking," Bishop said.

Sen. Rick Billinger, R-Goodland, said a culprit was malpractice insurance premiums paid by health professionals. In June, the Kansas Supreme Court ruled the state's cap on damages for noneconomic injuries in personal lawsuits was unconstitutional. The court's decision didn't apply to wrongful death cases or to punitive damages.

"We have to look at everything when we look at price," Billinger said.

Robert St. Peter, president of the nonprofit Kansas Health Institute in Topeka, told legislators the rise in health spending reflected an aging population, business concentration in the insurance industry, the volume of services consumed by patients, the price of pharmaceutical medicines and prevalence of chronic diseases, such as obesity.

In terms of industry concentration, Blue Cross and Blue Shield of Kansas controls 41% of people with insurance. That is a lower percentage than the top company operating in Oklahoma, Nebraska and Iowa, but higher than the heavyweight in Colorado and Missouri.

BCBS in Kansas possessed three-fourths of the market in Topeka and Manhattan, as well as 51% in Lawrence and 43% in Wichita.

"Look at Manhattan — 74% of the market by a single carrier. The next highest carrier is at 9%," St. Peter said. "That gives you some idea of what the concentration of insurance market looks like in Kansas. That's very important."

In 2017, Kansas had 1.8 million people with private health coverage, 815,000 with public health coverage and 243,000 who were uninsured.

St. Peter said Kansas could better control cost by lowering unnecessary emergency room use, expanding reliance on telemedicine and instituting "reference pricing" in the State Employee Health Plan. Under this model, the state would establish the maximum payment it contributed toward a drug, test or procedure.

He warned legislators not to shift the burden of paying for health care without lowering overall cost.

"You're pretty good at doing things that sometimes just shift who's paying for something, but it doesn't really change what's being paid overall," he said. "And that's the hard conversation to have. Slowing that overall rate of spending is more difficult."