State Actions to Prevent and Mitigate Adverse Childhood Experiences (ACEs)
This brief highlights the recent work of nine states (Alaska, California, Delaware, Maryland, New Jersey, Pennsylvania, Tennessee, Virginia, Wyoming) to prevent and mitigate adverse childhood experiences (ACEs) and to implement trauma-informed practices at the state level. Experiencing adversity in early life can affect a person’s health, well-being, and success into adulthood. COVID-19 has brought additional attention to the impact of ACEs and trauma across the lifespan, which may be exacerbated by disruption in the lives of families; increased family stressors; income, food, and housing insecurity; social isolation; and school closures. ACEs are common across sociodemographic groups; however, they do not impact all sociodemographic subgroups equally – elevating ACEs as an important locus for states to address health equity. To mount an effective response to ACEs, states are implementing holistic approaches to promoting resilience for children and their families and adopting approaches that combine universal training, access to screening and treatment, improved data collection and reporting, and a commitment to transformative, cross-agency cultural change.
Previous case studies:
Partnering with Tribal Nations for COVID-19 Vaccinations: A Case Study of Alaska
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Alaska’s vaccination outreach to Alaska Natives exemplifies a co-leadership model that prioritizes health equity and acknowledges historical trauma associated with previous public health emergencies. State and tribal leaders co-led the COVID-19 vaccination effort, including allocation, distribution, funding, and communication.
- As a result of the state and tribal partnership, Alaska Native communities have received vaccinations at rates equal to, and in many cases, above that of the average for all Alaskans.
- This brief is part of a series of work between NASHP, NGA, and the Duke-Margolis Center on health equity during COVID-19.
- Related: A Case Study of the Virginia COVID-19 Equity Leadership Task Force and Health Equity Working Group
State Officials Consider Patient Preferences when Evaluating Telehealth Evidence
When exploring new evidence about the effectiveness of telehealth, state policymakers want to know which interventions consumers prefer and are scalable for a range of populations. In addition to working to ensure that new telehealth tools are evidence-based and effective, officials want to make sure both patients and providers are interested in utilizing them.
The National Academy for State Health Policy’s (NASHP) Telehealth Affinity Group recently convened to discuss two studies funded by the Patient-Centered Outcomes Research Institute (PCORI):
- One ongoing study in rural Alaska is testing how well a new school-based screening and referral process – combined with a telemedicine consultation – can expedite the diagnosis of hearing loss in children. In the 15 participating communities, children are screened for hearing loss at school. Under the usual model, parents of children identified as needing a follow-up consultation are sent a letter with a request to take their child to a clinic. Under the intervention, the school and clinic work together to schedule a telemedicine appointment, during which a community health aide who is on-site at the local clinic works with specialists at a remote location to do follow-up testing. While the study does not yet have full results, the region saved $18 million in 2016 and 91 percent of patient travel to specialists was avoided. Data will be collected until February 2020.
- Another study investigated the use of patient portals – secure websites where patients can view health records and electronically communicate with doctors – among adults with chronic diseases in the Kaiser Permanente Northern California health system. Researchers wanted to understand how portal use impacted patients’ utilization of health care services. Among the eligible participants, 68 percent of patients created a patient portal. Portal use was associated with more office visits, fewer emergency department visits, and fewer preventable hospitalizations. Although portal use was connected to better outcomes, the results were somewhat limited as the study focused on a closed health care system. It is also difficult to discern if patients’ portal engagement impacted their behavior. For instance, it is unclear if these patients may have been proactive participants in their care even without the portal.
In response to these telehealth studies, affinity group members expressed their interest in understanding:
- How can an intervention be scaled to diverse populations? Would the rural, school-based intervention also work in urban areas? Could a similar telehealth invention be successful for adults who need follow-up care?
- How do patient preferences impact the adoption of telehealth? To what extent does the evidence support the success of a specific intervention itself, versus a specific population’s interest in utilizing it?
- What is the appropriate role of state officials in promoting evidence-based telehealth?
Scaling Interventions to Broad Populations
As affinity group members explore new evidence about telehealth, they expressed the desire to better understand how an intervention can be scaled to meet the needs of the populations they serve. The Alaska hearing loss study is of particular interest to officials because it offers a promising approach that could be adapted to connect a range of rural or underserved communities to specialists. The affinity group was very interested in the projected savings and how the community-focused design could be applied to their own states.
Members expressed skepticism about the applicability of the patient portal tool for the populations they serve. State officials questioned how this intervention might be scaled beyond a closed, integrated health system like Kaiser Permanente. For example, would an investment into an online portal for a state’s Medicaid population – some of whom may not have the same access to the internet as other higher-income populations – yield the same improved health outcomes?
Patient Preferences Impact Telehealth Adoption
A prominent theme from the discussions of both of the studies was the importance of patient preferences for care. Officials noted that evidence-based interventions that improve outcomes or lower costs must still be supported by patients and providers in order to warrant investment. As more telehealth evidence emerges, particularly relating to patient-focused tools, policymakers want to understand how likely members of their targeted populations are to use telehealth.
The Role of State Officials in Promoting Telehealth
Beyond adaptability, state officials want to know how they can invest or most effectively promote the adoption of telehealth through their roles as payers and/or regulators. Officials wonder if there could be opportunities to use existing funding to pay for or incentivize use of patient-directed telehealth tools, like an online portal, to work toward improved health outcomes for targeted populations. There is also interest among the affinity group in considering how state agencies could promote or encourage community-level collaboration, similar to the Alaska example, to implement a successful telehealth intervention.
While the two studies prompted more questions, state officials value the research investment in telehealth. While the affinity group discussions often raise issues outside the scope of testing specific interventions, researchers may benefit from understanding the broader context state officials work within when making or changing policy. It is critical for state officials to understand scalability, how to engage diverse, dynamic populations or to have tools to decide whether or not their states can make the investments needed to implement new interventions.
NASHP’s Telehealth Affinity Group will continue to meet and discuss emerging PCORI research on telehealth in the coming months. To learn about the group’s first meeting, read the NASHP blog, States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth.
States Utilize Cross-Agency Resources to Address Health Care Workforce Shortages
The National Academy for State Health Policy examined how Indiana and Alaska leverage their resources and build new partnerships to implement innovative, cross-agency approaches to bolster their health care workforces. These case studies explore:
- Cross-agency coalitions that develop and implement innovative workforce strategies;
- Opportunities to use data to identify and address workforce shortages;
- Strategies to support and promote a non-traditional health care workforce; and
- Options to support education and training for current and future health care workers.
Read or download: Case Study: How Indiana Addresses Its Health Care Workforce Challenges
Read or download: Case Study: How Alaska Addresses Its Health Care Workforce Challenges
Additional resources:
- Read State Agencies Partner to Address Health Care Workforce Shortages, which highlights state and federal resources, such as Workforce Innovation and Opportunity Act funding, Section 1115 waivers, and federal and state loan repayment programs, that can be used to address workforce challenges.
Review presentations from #NASHPCONF18’s session: May the (Work) Force Be With You.
Toolkit: State Strategies to Improve Health Outcomes for People Living with HIV
Collaboration between state health department HIV programs and Medicaid is integral to providing quality, comprehensive care to people living with HIV (PLWH). With consistent, well-coordinated care and access to antiretroviral therapy (ART) many PLWH can achieve virologic suppression. Those who achieve sustained virologic suppression tend to have better health outcomes and a reduced risk of transmitting HIV to others. Collaboration and partnership can be challenging in many states, particularly when the Medicaid and state health departments are housed in separate agencies. There are, however, numerous strategies states can implement to improve collaboration and partnership between Medicaid and state health departments to implement policy and program changes to achieve this goal.
In 2017, NASHP completed work with 19 states to support them in identifying and implementing policy and program changes to improve rates of sustained virologic suppression among Medicaid and CHIP beneficiaries living with HIV. While working with these states, NASHP identified that state officials needed additional resources on a variety of topics, such as data sharing and use and quality improvement.
This toolkit, supported through a cooperative agreement with the Health Resources and Services Administration, is intended provide state officials with tools and resources, including issue briefs, webinars, and presentations, they need to improve rates of sustained virologic suppression. New items will be added to the toolkit on a regular basis, providing state officials with up-to-date information and timely policy resources.
Tools and Resources
Publications
One-Page Summary: HIV Health Improvement Affinity Group Evaluation Report
March 2019
This two-page summary 2019 highlights state action plans designed to increase viral suppressions and improve health outcomes for people living with HIV enrolled in Medicaid.
HIV Health Improvement Affinity Group Evaluation Report
March 2019
This full report explores the state action plans that 19 states and Medicaid agency staff developed to increase viral suppression and improve the health of people living with HIV. Federal agency partners and NASHP supported this one-year, peer-to-peer learning initiative.
States play critical roles in ensuring that people living with HIV (PLWH) have access to quality care through their Medicaid and Ryan White HIV/AIDS programs. PLWH can be among the most medically complex individuals covered by state health programs, and their care can cost five-times the average Medicaid beneficiary. Given limited resources, state policymakers are working to develop policies and strategies that are accessible, well-coordinated, and effective. This three-part series explores policy levers and strategies that states are using to focus limited resources and provide comprehensive and accessible care to PLWH.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
How States Use Medicaid and State Health Department Data to Improve Health Outcomes of People Living with HIV
December 2017
This issue brief discusses key considerations and promising state strategies to share and then analyze Medicaid claims and HIV surveillance and Ryan White HIV/AIDS Program data. Analyses of these interagency data sets can help inform state and local policy and program changes aimed at increasing rates of virologic suppression for Medicaid and CHIP beneficiaries living with HIV. The brief also provides an overview of select data sets that states may be interested in sharing. This issue brief was written as part of the HIV Health Improvement Affinity Group project.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
States Share Data to Improve the Health of People Living with HIV
December 2017
This blog presents lessons learned from three HIV Health Improvement Affinity Group states—Alaska, Louisiana, and Maryland—that are working toward sharing and analyzing Medicaid and state health department data to ultimately increase rates of virologic suppression among people living with HIV. This blog was written as part of the HIV Health Improvement Affinity Group project.
Better Together: How Cross-Agency Data Sharing Can Improve the Care Continuum for People Living with HIV/AIDS
October 2017
The state of Georgia leveraged a data sharing agreement between its public health and Medicaid departments in order to assess care quality for Medicaid beneficiaries living with HIV. Data use agreements are critical for agencies interested in sharing data. This blog was written as part of the HIV Health Improvement Affinity Group project.
As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model they call “one-stop shopping.” This issue brief showcases the CORE Center’s model and how it is partnering with the Illinois Department of Health to improve care for people living with HIV. The accompanying webinar can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: Health Homes for People Living with HIV/AIDS
June 2016
This case study highlights Wisconsin’s health home program for Medicaid beneficiaries living with HIV, which is the first and only health home program exclusively for this population. Wisconsin’s experience may assist other states considering the health home state plan option as a strategy to support integrated care for Medicaid beneficiaries living with HIV. This case study was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: HIV-Specific Quality Metrics for Managed Care
June 2016
This case study highlights New York’s use of HIV-related performance metrics to incentivize its Medicaid managed care plans to improve care for their members living with HIV. Their experience may assist other states considering how to incentivize quality improvement in their managed care program. This issue brief was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Strategies for Coordination Between Medicaid and Ryan White HIV/AIDS Programs
November 2013
This policy brief discusses the importance of coordination between a state’s Medicaid agency and the Ryan White HIV/AIDS Program (RWHAP) to ensure that people living with HIV have access to comprehensive, high-quality care. NASHP interviewed Medicaid and RWHAP officials in 14 states about successful coordination efforts. This brief highlights those examples, along with additional promising practices for coordination that facilitate delivery improvements for people living with HIV. An accompanying webinar can be accessed here. The Health Resources and Services Administration (HRSA) provided support for this issue brief and webinar.
Webinars and Presentations
Overview of state and federal HIV programs
State Health Department HIV Programs: An In-Depth Look
February 23, 2017
View the webinar | Download the slides
The purpose of this webinar was to provide Medicaid and other state officials with information about the structure and components of state health department HIV programs and resources, as well as opportunities for collaboration between these programs and Medicaid. The Centers for Disease Control and Prevention discussed state HIV surveillance and prevention programs and the Health Resources and Services Administration discussed the Ryan White HIV/AIDS Program. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
Download the slides
This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Health Resources and Services Administration and HIV/AIDS Bureau Update
December 6, 2016
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Laura Cheever, Associate Administrator for the HIV/AIDS Bureau within the Health Resources and Services Administration presented an overview of the Bureau’s priority areas and a preview of 2015 Ryan White HIV/AIDS Program Services Report data. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Overview of state Medicaid programs
The Medicaid Program: An In-Depth Look
February 16, 2017
View the webinar | Download the slides
While Medicaid programs vary greatly across states, the purpose of this webinar was to provide state health department and other officials with information about the structure and components of this program, as well as opportunities for collaboration between Medicaid and state health departments. The Centers for Medicare & Medicaid Services and NASHP presented about Medicaid structure, eligibility, benefits, financing, payment and delivery, as well as waivers and state plan amendments. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Interagency collaboration
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
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Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
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This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Opportunities for state policy improvement
Webinar: Increasing Rates of Virologic Suppression: Promising Practices from HIV Health Improvement Affinity Group States
Wednesday, Dec. 6, 2017
View the webinar | Download the slides
Increasing rates of virologic suppression among people living with HIV is critically important to improving their quality of life and decreasing the risk of further HIV transmission. For the last 12 months, the HIV Health Improvement Affinity Group has worked with state health departments and Medicaid agencies from 19 states to develop and implement performance improvement projects aimed at improving rates of sustained virologic suppression among Medicaid beneficiaries living with HIV. This webinar featured leaders from the Office of HIV/AIDS and Infectious Disease Policy in the US Department of Health & Human Services, the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Centers for Disease Control and Prevention. It also featured Affinity Group states, Alaska and North Carolina, that shared lessons learned and best practices from their performance improvement projects.
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
View the webinar | Download the slides
It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group: Policy and System Change
December 7, 2016
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This presentation highlighted the role that Medicaid plays in ensuring many people living with HIV have access to comprehensive, high quality care. It also showcased policy changes that states could implement to improve access to and quality of care for beneficiaries living with HIV, including increased access to HIV testing, benefit design changes, and network adequacy standards. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
Download the slides
Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
Download the slides
Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
Download the slides
This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Data sharing and use
Data Sharing and Use: Creating Platforms for Exchange, Insight, and Action
May 24, 2017
View the webinar | Download the slides
This webinar highlighted the importance of building technological infrastructure to link and use data sets across state agencies, programs, and provider groups, as well as provided details about available 90/10 match funding to support infrastructure development. Louisiana and the District of Columbia both shared their experiences with developing information technology infrastructure to share data among agencies and programs. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data Transfer and Use: Navigating Federal and State Laws and Regulations
March 28, 2017
View the webinar | Download the slides
This webinar discussed various data sharing regulations at the state and federal level, such as HIPAA and 42 CFR Part 2, and how these regulations may impact the sharing and use of HIV-related data across state agencies. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
North Carolina’s Engagement in Care Database for HIV Outreach (NC Echo): A Collaborative Effort
December 7, 2016
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North Carolina presented on its Engagement in Care Database, which analyzes data from Medicaid claims and health department surveillance and Ryan White HIV/AIDS Program to identify people living with HIV that are not engaged in HIV care. State program staff then use this information to target outreach to these individuals to get them re-engaged in HIV care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Public Health Innovation: Emerging Opportunities for Leveraging Health Systems Data
December 6, 2016
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This presentation explained why data sharing between Medicaid and state health departments is critical to better understanding utilization patterns and health outcomes for people living with HIV. It also identified key considerations for states interested in advancing this work. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Data analysis and presentation
How Data Visualization Efforts Impact Care and Decision Making
July 20, 2017
View the webinar | Download the slides | Presentation handout
The way in which data is presented is important when trying to increase stakeholder understanding and engagement on a particular issue. This webinar discussed strategies states can use to tailor their communication of data to specific audiences. The Massachusetts Department of Public Health shared how it designed a new website about the impact of the state’s opioid epidemic to be a rich, user-friendly resource for policymakers and community members. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
Download the slides
Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Provider- and system-level quality improvement
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
View the webinar | Download the slides
It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data, Delivery, and Decisions as Levers for Enhancing Whole-Person Care for People Living with HIV: Lessons from the Ruth M. Rothstein CORE Center
January 26, 2017
View the webinar
As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model it calls “one-stop shopping.” This webinar featured speakers from the CORE Center and the Illinois Department of Health who shared lessons learned from their partnership to improve care for PLWH. The accompanying issue brief can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Process Improvement Methods and Tools
November 18, 2016
View the webinar | Download the slides
Dr. Kevin Larsen from the Centers for Medicare & Medicaid Services shared methods and tools that states can use to design quality improvement initiatives. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Addressing social determinants of health
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
Download the slides
This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
States Share Data to Improve the Health of People Living with HIV
| Virologic Suppression occurs when the amount of HIV in the blood is lowered to below 200 copies per milliliter or undetectable levels.PLWH are more likely to achieve and maintain virologic suppression when they have access to high-quality, coordinated and comprehensive care, antiretroviral therapy, and support services. A substantial body of research shows that virally-suppressed people have better health outcomes and are at significantly reduced risk of sexually transmitting HIV to others. Source: Centers for Disease Control and Prevention. “HIV Treatment as Prevention.” Accessed November 13, 2017. https://www.cdc.gov/hiv/risk/art/index.html. |
Research shows that people living with HIV (PLWH) who achieve and maintain virologic suppression at undetectable levels have better health outcomes and reduced risk of transmitting HIV to others. As a result, many states have made increasing rates of virologic suppression in Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries living with HIV a high priority. States are increasingly using data analytics to better understand PLWA’s health care engagement and outcomes in order to improve state policies and programs.
In 2016, Medicaid and health departments from 19 states with diverse geographic regions and varying HIV rates joined the HIV Health Improvement Affinity Group. The states represent more than 50 percent of people living with HIV in the United States as of 2014.
Each affinity group state developed a quality improvement project and received technical assistance to strengthen state strategies that increase virologic suppression for Medicaid and CHIP beneficiaries living with HIV. Overwhelmingly, these states identified the need to understand this population’s service utilization and health outcomes in order to inform policy and program improvements. To do this, states can share and compare data sets from HIV prevention, treatment, and surveillance programs and Medicaid. While data sharing and analysis can be complex — due to federal and state laws and the need for a strong information technology (IT) infrastructure — states in the affinity group are leading the way.
| HIV Health Improvement Affinity Group The HIV Health Improvement Affinity Group (HHIAG) provided support to 19 state Medicaid and public health department teams (highlighted in blue) working to increase rates of sustained virologic suppression among Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries living with HIV.The HHIAG was a joint initiative of the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration, in collaboration with the Health and Human Services’ Office of HIV/AIDS and Infectious Disease Policy, and in partnership with NASHP.  |
Prior to the Affinity Group, there was a very limited working relationship between the Alaska HIV Program and Medicaid. Their collaboration throughout the affinity group allowed leaders from both programs to establish a data use agreement (DUA), providing the HIV Program access to Medicaid claims data. HIV Program staff have completed a match of HIV surveillance data to Medicaid claims to better understand the utilization of services by people living with HIV enrolled in Medicaid and their HIV viral load. HIV Program and Medicaid staff believe this data analysis will allow them to better target limited resources to PLWH who are not regularly seeking HIV care and/or filling their medications.
Maryland state officials recognized the need for a DUA between the Maryland Department of Health and the Office of Health Care Financing (Medicaid) so that HIV program staff could access Medicaid claims data. They are now in the process of finalizing a DUA that will allow regular transfers of Medicaid claims data to the state’s HIV Program. While the DUA was being written, Maryland created a list of claims-based codes that could indicate if a beneficiary is HIV positive, received HIV testing, or received pre-exposure prophylaxis (PrEP). Once the DUA is in place, these codes will be used by data analytics staff to identify and describe beneficiaries using that criteria. Maryland will also create data files of HIV-positive beneficiaries for future analysis of claims utilization.
Louisiana finalized a DUA in 2014 that allows Medicaid claims data to be shared with the state health department. The state runs quarterly analyses that compare Medicaid claims data with HIV surveillance data to identify Medicaid beneficiaries who have an HIV diagnosis, but are not accessing or engaging in HIV care, and whether or not they are virally suppressed. Medicaid managed care plans in the state receive updates about their enrolled members’ results from each quarterly analysis. Based on these reports, plans can reach out to members who are not yet engaged in HIV care and/or not virally suppressed, and help them access necessary services. Louisiana currently incentivizes plans to increase virologic suppression rates by including viral load suppression as one of nine incentive-based quality metrics. If plans do not achieve an established target for an incentive-based measure, they may be subject to monetary penalties.
More promising strategies, state examples, and technical assistance resources describing how states can improve rates of viral load suppression will soon be published in a NASHP toolkit and explored in a national webinar. Visit NASHP.org and read its weekly e-newsletter for information about the release of the toolkit in mid-December.
To register for the webinar on Dec. 6, 2017, click here.
HHS Invites More 1332 Waiver Requests Citing Alaska
Quick Summary of the Alaska Reinsurance Plan
Yesterday, Health and Human Services (HHS) Secretary Tom Price issued a letter to governors encouraging them to take advantage of Sec. 1332 State Innovation Waivers under the Affordable Care Act (ACA) and cited Alaska ‘s 1332 waiver request to HHS as an example. Alaska’s waiver seeks federal funds to support a reinsurance plan to stabilize its individual insurance market. The proposal has been deemed complete by HHS and is under review but has not yet been approved. What exactly is Alaska proposing to do and how?
Insufficient funding of the federal ACA reinsurance program (which ended for claims incurred after calendar year 2016), and the underfunding of the federal ACA risk adjustment program, were factors in extraordinary premium increases in the individual markets in the states. In Alaska, state action was provoked when the one insurer operating in the individual market proposed rate increases more than 40 percent higher than 2016.
In the fall of 2016, Alaska’s legislature created the Alaska Comprehensive Health Insurance Fund (ACHI), that sunsets in June 2018, and authorized the Division of Insurance to apply for a 1332 waiver. The ACHI is designed to reinsure the one remaining insurer for costs to treat people with life-threatening, chronic conditions; the specific conditions are defined in regulation rather than the authorizing statute. As a result, the health insurer scaled back 2017 premium increases to seven percent. Alaska funded the program by using $55 million of the $64 million generated in 2015 from a 2.7 percent tax on health insurance premiums. The new law expanded the premium tax base to all insurance premiums – not just health insurance.
The state’s Division of Insurance tracked how the investment in reinsurance lowered premiums and thereby lowered the cost to the federal government for advanced premium tax credits (APTC); as premiums went down, fewer federal dollars were needed to make premiums affordable through APTCs.
APTC and Individual Enrollment
With assistance from Oliver Wyman actuaries, Alaska projected what the costs for APTCs would have been by year, absent the reinvestment fund, and documented projected savings to the federal government. As the charts demonstrate, Alaska has sought a 1332 waiver to secure from the federal government the funds that would have been spent on APTCs to reinvest in the reinsurance plan to maintain premium stability and reduce the state’s liability for those costs. Alaska notes that the reinsurance plan alone is inadequate and other actions are under consideration to increase the affordability of coverage, although the reinsurance plan has stabilized the individual market.
All eyes are on Alaska to see if their 1332 request is approved and how the reinsurance plan and other strategies under consideration address costs in the individual market.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.
The State of State Health Policy: Governors’ 2016 State of the State Addresses
State of State speeches provide governors with an opportunity to highlight recent policy successes as well as outline key plans and issue areas of focus for the coming year. These speeches are generally strong indicators of governors’ main priorities and sometimes also include specific proposal suggestions and funding recommendations for deliberation by legislatures.
Currently, 31 governors are Republican, 18 are Democrats and one is an Independent. Two states—Kentucky and Louisiana—elected new governors in 2015. So far this year, 40 governors have outlined policy priorities through state of state speeches and/or budget addresses.[1] The chart and descriptions below summarize some of the main health-related themes from these speeches.
See a state-by-state comparison
Six governors mentioned the issue of more broadly addressing population health and building healthy communities.
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Launching Great State 2019 Plan in honor of state’s upcoming 200th birthday; initiative will focus on addressing longstanding problems from healthcare to prison reform and will involve building opportunities for citizens, and promoting education, healthcare, access to technology, job growth and economic opportunity |
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Highlighted poverty’s negative effects and mentioned state’s Two Generation initiative to address poverty that links with the state’s efforts to be the healthiest in the nation; initiative recognizes that residents’ health has economic and overall quality of life impacts; also importance of reducing children’s screen time and the need to promote healthier behaviors such as involvement in outdoor activities |
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Will be investing in issue of homelessness, which will include addressing the needs of the most vulnerable homeless, such as those with chronic health conditions |
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Need to make more coordinated investments and transform towards focusing more intensely on prevention and public health and paying for outcomes rather than volume and services |
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Noted that safe and healthy communities are the foundation of the state; to maintain the state’s high quality of life investments should continue in priorities that support economic growth |
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Mentioned consumer health concerns regarding access to safe and healthy food and the need for meaningful food labeling |
In addition to mentioning health care costs within the context of Medicaid, eight governors also spoke about state health care costs more broadly; often mentioning costs associated with state employee health benefits.
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Noted that state has not allocated enough funding to cover future retiree health benefits for state workers |
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Identified sharply rising health care costs as the state’s biggest challenge, particularly costs of state employee health plans; also importance of shifting from fee-for service health care to a system focused on high quality and affordable outcomes, and ensuring that individuals appropriately use care to help reduce overall costs |
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Commented on the rising costs of mandated health care expenditures for state employees |
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Mentioned state employee health care obligations as one of the state’s biggest fixed expenses, but recent changes to how these obligations are funded will save costs in the future |
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Noted state budget crisis and need for new revenue to avoid severe cuts in assistance programs for disabled individuals and other health programs and potentially having to close safety net hospitals |
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Noted that if state does not address $2 billion budget deficit will have to make significant cuts to basic state services, including health programs such as prescription drug assistance for seniors, services for individuals with mental illness and disabilities, and home and community-based services |
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Mentioned the rising cost of health care as the most significant challenge to the state’s budget and the overall economy as well as creates challenges for families and businesses; noted state’s current work to shift from fee-for-service to an all-payer model focused on better health outcomes and targeted provider spending |
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Commented on the need to reform the administration of state employee health insurance to achieve savings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs.
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Mentioned commitment to implement Medicaid reforms to improve the state’s Medicaid program |
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Noted positive benefits of state’s Medicaid program but that there has been a significant rise in state Medicaid costs; requests legislature consider proposal to restructure taxes on Medicaid managed care organizations |
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Commented that state Medicaid costs have increased from $2.6 billion in FY2013 to $3.1 billion in FY2017 |
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Mentioned plans to move to a Medicaid managed care system to improve care coordination and address significantly rising state Medicaid costs |
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Recent reforms and modernizations to Medicaid program have demonstrated cost savings and also resulted in more client services and increased provider reimbursement rates |
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Access to in-home Medicaid services for individuals with developmental disabilities has significantly improved |
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Noted significant rise in state Medicaid costs |
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Highlighted the success of TennCare as a well-run system with high customer satisfaction ratings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs. Thirteen governors mentioned Medicaid expansion in their speeches. Eight were governors that have not implemented expansion, and five of these governors spoke about the need to expand Medicaid or find another state-specific solution to cover the uninsured (Missouri, South Dakota, Utah, Virginia, and Wyoming). Two governors (Kansas and Nebraska) expressed continued opposition to expansion. Kentucky’s newly elected governor mentioned plans to transform the delivery of publicly assisted health care and to make changes to the state’s traditional Medicaid expansion, although the proposed budget contains funding for expansion in its current form.
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Noted expansion has resulted in greater health coverage for residents and state has benefited from increased federal revenue from expansion |
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Mentioned expansion has resulted in greater health coverage for residents |
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Highlighted the work of cabinet in exploring Medicaid expansion alternatives; also mentioned recently released plan to provide state-funded primary care |
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Mentioned state’s unique expansion program has resulted in increased access to health care and is based on personal responsibility |
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Noted continued opposition to implementing expansion |
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Mentioned plans to transform delivery of publicly assisted health care and to make changes to the state’s current Medicaid expansion; proposed budget contains funding for current expansion |
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Suggested state should act to cover the uninsured through expansion; can develop a state-tailored solution that rewards work and incorporates personal responsibility |
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Noted continued opposition to implementing expansion |
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Urged legislators to support continuation of the Health Protection Program, the state’s Medicaid expansion program, which has increased access to behavioral health services but will end in December 2016 without legislative action |
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Noted opposition to ACA but importance of considering expansion to make the best decisions for the state; current negotiations with federal officials to change reimbursement process for services provided to Indian Health Services enrollees could cover the state’s expansion costs; will not move forward on expansion without legislative budget authority or if any new general funds are needed; also detailed how cost projections for the expansion population were developed; encouraged any expansion legislation to include language to end expansion if the federal match is reduced |
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Noted flaws of ACA but urged legislators to find a state-tailored solution to covering the uninsured |
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Urged legislators to consider Medicaid expansion through a bipartisan, state-tailored solution |
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Noted opposition to ACA overall but that state should craft tailored expansion plan; commented on loss of federal revenue from not expanding affecting hospitals and businesses, and uninsured individuals lacking coverage; cited many organizations that support expansion (e.g. state business alliance and chambers of commerce) |
Two governors spoke about the topic of the ACA’s exchanges in their speeches.
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Mentioned plans to cease operations of the state’s exchange, Kynect, and that individuals will enroll through the federal exchange |
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Noted improvements in eligibility determinations and access to the state’s Health Connector in the past year |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors’ frequently highlighted strategies that have been implemented or that they plan to implement to increase access to behavioral health services.
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Highlighted the issue of drug addiction; plans to convene a group of experts on substance abuse issues, recovering addicts and providers to identify appropriate treatments and reduce barriers to care |
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State is working to improve access to mental health care through State Innovation Model project; also plans to address links between suicide, mental illness and guns |
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State has significantly increased access to substance use treatment and is working with law enforcement to address overdoses; budget includes funding to provide team-based care for individuals in need of intensive treatment services; also plans for the Department of Health and Social Services to work with primary care providers to identify substance abuse issues earlier |
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Mentioned behavioral health issues as the underlying cause of many social, health and economic challenges and that mental health is the most pressing unmet health issue facing the state |
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Local behavioral health crisis centers have been effective; proposed budget includes funding for an additional center |
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Need to increase treatment options for drug addiction; will create task force on enforcement, treatment and prevention; also plans to build the first new mental health hospital in a generation |
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Highlighted the importance of addressing the needs of individuals with severe mental illnesses; will be launching a crisis prevention program for individuals ages 21 to 35 with severe mental illnesses and substance use disorders |
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Recent passage of state laws that increase access to substance abuse treatment; state still needs to “double down” on drug addiction and to treat it as an illness; committed to providing $100 million to improve access to mental health and substance use treatment by providing higher reimbursement rates for services and providers; plans to increase funding for three Accountable Care Organizations focused on providing coordinated physical and behavioral health treatment for Medicaid patients |
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In the past five years the highest amount of funding in the state’s history has been provided for mental health; legislation was passed to reduce prescription drug and substance abuse fatalities |
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Recent investments of over $700 million in the state’s mental health system to restore prior service cuts, but additional focus on the issue is still needed; proposed budget includes funding directed towards building a stronger mental health system |
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Substance abuse has become one of the most significant challenges in the state; have invested in treatment services and resources to publicize services, updated prescription drug monitoring efforts, and implemented other measures to reduce the oversupply of pain medication |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. The issue of heroin and other types of opioid abuse and overdoses were specifically mentioned by a number of governors in their remarks.
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Recently passed state law allowing healthcare providers to make an antidote available to address opioid overdoses and to allow Medicaid to cover inpatient detoxification |
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Plans to address heroin and opioid addiction; proposed budget includes funding for treatment programs and continuation of efforts to monitor prescription drugs |
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State is working to address heroin and opioid addiction through a state-level task force |
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Legislation being developed to address the heroin and opioid abuse epidemic by building capacity in prevention, education, and treatment efforts |
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Need for a prescription drug monitoring program to address the opioid abuse epidemic |
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State has worked to address the heroin and opioid abuse crisis but the issue remains the most urgent public health and public safety concern; efforts are underway to strengthen the state’s prescription drug monitoring program and improve access to treatment, but need further funding for law enforcement and efforts to strengthen prevention, treatment and recovery initiatives |
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Plans to launch a treatment intervention pilot program for individuals recovering from drug overdoses; individuals in recovery will help lead the intervention programs |
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State views opioid overdoses as a public health crisis; aiming to reduce overdoses by one-third in the next three years by investing in treatment, overdose reversals, prevention and recovery |
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State has coordinated trainings for first responders on administering Narcan, an antidote for opioid overdoses; plans to introduce legislation to expand access to Narcan without a prescription |
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Proposing funding to make a pilot program for overdose drug naloxone permanent; also funding for needle exchange programs, additional state staff resources and to develop a new treatment hub |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals, and providing mental health and substance use treatment services rather than incarceration when appropriate.
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Will be focusing on providing drug treatment and counseling to justice-involved individuals to help reduce recidivism |
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Mentioned justice reforms have diverted justice-involved individuals with substance use disorders to treatment rather than incarceration when appropriate |
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Bipartisan commission to reform the criminal justice system recommended enhancing cognitive behavioral therapy and substance abuse treatment programs in the corrections system |
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As part of the state’s justice policy reforms, will be focusing on rehabilitation instead of incarceration and on looking at funding models for drug and mental health courts |
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Proposing $1.6 million to reduce the number of severely mentally ill individuals cycling through jails and emergency rooms and to direct them to treatment instead |
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With reductions in the state’s prison population, one of the correctional facilities has been closed and will be converted into a certified drug abuse treatment facility for justice-involved individuals |
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Importance of addressing the behavioral health issues of justice-involved individuals; proposed budget includes funding for new crisis triage centers, mobile crisis response teams, and community behavioral health clinics |
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State has significantly increased the number of drug and DUI courts; more non-violent justice-involved individuals are receiving community treatment rather than being incarcerated |
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State has increased the number of drug recovery courts, resulting in reduced incarceration costs; proposing to invest more in these courts in order to offer services in all counties |
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Need to address issue of individuals with severe mental illnesses who cycle between jails and emergency rooms; proposed budget includes funding for four new 16-bed crisis triage facilities and three new mobile crisis teams |
Five governors noted issues related to the health care workforce, primarily commenting on strategies to address shortages.
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Mentioned physician and dentist shortage in nearly all of the state’s counties, and outlined plans to increase funding for medical scholarships and loan forgiveness for students committing to serve in underserved areas; also aims to create tax credits for rural providers and increase funding for 12 new residency programs |
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Noted that programs to train individuals in the health care field are expanding |
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Commented on need to address state’s lack of primary care physicians by maintaining funding for physician residency slots and providing medical loan reimbursement; also requests that the Board of Education work with the medical community and higher education institutions to develop plans to address the growing need for healthcare providers |
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Mentioned current state legislation that would permit the state to enter into a compact with other states to allow medical licenses to be interchangeable across states |
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Commented on how plans to expand employment training programs will help address healthcare workforce shortages; a task force will focus on developing innovative solutions to further address these shortages |
Some governors mentioned other specific health topics in their speeches, either as recent accomplishments or as future plans. These included topics such as enhancements to autism coverage, improvements in health coverage eligibility determinations, or lowered prison pharmacy costs.
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Mentioned that state will be providing health care coverage to children of undocumented workers; also state leads the nation in providing Medicaid home-based care, which also gives jobs to health care providers |
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Noted plans to partner with a national nonprofit organization to improve access to contraceptive options by offering better training for health care providers |
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Mentioned that in recognition of the need for private sector resources for Maui’s public hospitals, recently transferred hospital management to Kaiser Permanente |
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Will be forming a working group to address rural health care delivery issues |
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Addressed the water crisis in Flint and proposes support for increasing children’s access to health care and treatment for health issues associated with elevated blood lead levels |
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Highlighted passage of autism legislation to ensure that appropriate services are available through health plans; will expand services at existing autism centers and build a new center |
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Mentioned improvements at state’s Department of Health and Human Services have streamlined low-income residents’ access to nutrition assistance and other assistance programs |
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Mentioned that Department of Correction worked with TennCare to lower prison pharmacy costs annually by $5 million; proposed budget includes funding for a mobile seating and positioning unit in the Department of Intellectual and Developmental Disabilities |
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Noting the importance of helping individuals cope with health and mental health care needs to retain workplace talent, mentioned a recently completed informational kit for employers to provide to employees caring for family members with dementia or Alzheimer’s disease |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
