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States Address Racial and Ethnic Disparities in their COVID-19 Responses and Beyond
More than a year into the pandemic, COVID-19 is proving to be a complicated syndemic with political, economic, and social factors influencing who is most at risk of infection and death. With communities impacted by structural racism facing higher COVID-19 infection and mortality rates, state responses and recovery plans are focusing on equity.
The latest update to the National Academy for State Health Policy’s (NASHP) interactive map and chart, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, highlights the cross-sector actions states are taking to reduce COVID-19 inequities. Many are:
- Developing strategies to create resilient public health systems capable of weathering future challenges; and
- Developing longitudinal, agency-level changes, such as instituting racial equity impact assessments to determine the impact of state policies on various racial and ethnic groups.
States Emphasize Equity in COVID-19 Response
Washington, DC has prioritized equity in its coronavirus response and vaccine distribution strategies. The Reopen DC Taskforce designated a subcommittee to focus on vulnerable populations to address the inequities of the pandemic including the disproportionate impact on African American individuals in case counts and deaths. The subcommittee has assembled several recommendations addressing social and economic determinants of health for Mayor Muriel Bowser to consider as she works to create an equitable reopening plan based on science and tailored to community needs. The District is focusing on prevention, health outcomes, and access to resources by collecting and publishing race/ethnicity data to guide their initiative to reopen the District. The District is also exploring philanthropic partnerships to help provide health and economic support to communities of color. The committee’s recommendations focus on:
- Employment and income;
- Education;
- Food environment;
- Health and medical care;
- Housing;
- Transportation;
- Outdoor environment; and
- Community safety.
The committee recommends sustaining investments in the expansion of supportive and affordable housing for domestic violence victims and incarcerated individuals re-entering their communities, as well as non-congregate housing for people experiencing homelessness.
The committee also recommends incentivizing employers who accommodate extended work-from-home requests from employees and working with pharmacies and other medical corporations to prevent treatment shortages in underserved areas.
The DC Council has also passed legislation to create the Council Office of Racial Equity (CORE). CORE recently released a report in March examining racial equity in the District’s vaccination rates and practices, and proposing best practices to ensure the District can ensure a racially equitable process moving forward. For example, to ensure equitable vaccine distribution, the District prioritizes doses for individuals living in high-need zip codes and has restricted registration on certain days to allow only those individuals to sign up on the vaccine portal or call the vaccine hotline. CORE is currently working on another report that focuses on a racially equitable economic recovery.
In Illinois, the Department of Public Health established a COVID-19 Health Equity Task Force to work across the department and with other relevant state and local entities to assess health concerns of minority communities and create and maintain culturally sensitive programs. The task force launched a COVID-19 text messaging system that includes a Spanish-speaking option. The department also supported the City of Chicago, in partnership with the city’s chief equity officer, to create the Racial Equity Rapid Response Team (RERRT) to address the disproportionate effects of the pandemic on communities of color. The city experienced a significant improvement in vaccine administration to communities of color by February 2021 as a result of RERRT’s oversight and involvement.
Georgia’s Department of Public Health created a COVID-19 Health Equity Council to ensure equity in COVID-19 vaccination education and distribution efforts in communities most affected by COVID-19. Members of the council represent community-based organizations, news stations, chambers of commerce, and universities. The council will work with Georgia’s 18 public health districts to address COVID-19 concerns.
State Actions to Address Equity Beyond the Pandemic
States are making financial and cross-agency leadership commitments to ensure equity is the focus of their work moving forward. Washington, DC, Illinois, Indiana, and Washington State have recently hired or are in the process of hiring cabinet-level positions to oversee inter-agency diversity, equity, and inclusion (DEI) initiatives. States are also implementing cross-sector equity plans and making significant investments in identified program and policy areas.
Washington’s state legislature passed HB 1783 in 2020 to create the Office of Equity. Lawmakers explained, “the legislature finds that a more inclusive Washington is possible if agencies identify and implement effective strategies to eliminate systemic inequities.” In February 2021, Gov. Jay Inslee named a director of the program to be in office by March 8. The office will be staffed by eight people and is tasked to develop and implement a five-year equity plan for the state. Staff will work with other state agencies to help create and implement DEI plans.
In his $365 million equity policy package, Gov. Inslee earmarked $2.5 million from the state’s general fund for the office. Other state equity priorities include:
- $10 million for the Washington COVID-19 Immigrant Relief Fund;
- Funding for the Office of Minority and Women’s Business Enterprises to launch the Washington State Toolkit for Equity in Public Spending to increase the number of minority and women contractors;
- Funding for the Department of Financial Institutions to address racial wealth inequities by working with financial institutions, federal, state, and local governments, and community partners;
- $79 million to support residential broadband connection for families and $6 million for a Digital Navigator Program that enables navigators to provide one-on-one support for students, English language learners, older adults, and individuals searching for work; and
- $8.4 million for students who experienced foster care or homelessness, including $3 million for pre-apprenticeship training.
In Florida, bills introduced in the House of Representatives and State Senate (HB 183 and SB 404) require each county health department to designate a minority health liaison. The liaison will collaborate with the state Office of Minority Health and Health Equity on implementation of programs, policies, and practices. Examples of these activities include:
- Data analysis for disparities in health status, health care quality, and access to care for racial and ethnic minority populations;
- Demonstration projects to increase health equity;
- Community health workers working to improve cultural competency and individual and community self-sufficiency;
- Analysis of a community’s risk for involvement in the adult and juvenile legal system and foster care system, or risk of homelessness. Available support programs and diversion programs addressing these areas will also be examined; and
- Developing and executing programming for individuals with limited English proficiency to help them better access health care services.
Racial equity impact assessments are another strategy to address equity beyond the pandemic. These assessments help determine the impact of a policy or budget item on racial and ethnic groups. Seven states (CO, CT, FL, IA, MD, NJ, and OR) require racial impact statements. The following states recently took action to establish racial impact assessments:
- Maine’s legislature passed LD 2, a bill that requires the inclusion of racial impact statements in the legislative process. The bill allows legislative committees to request state agencies to provide analysis of the impact of pending legislation on historically disadvantaged racial populations.
- The Virginia General Assembly passed HB 1990, a bill that allows the chairs of the House Committee for Courts of Justice and Senate Committee on the Judiciary to request racial and impact statements from the Joint Legislative Audit Review Commission. Committee chairs may not request more than three racial and ethnic impact statements during a single session.
- The Washington, DC Council passed L23-0181, the Racial Equity Achieves Results (REACH) Act. Among other activities to ensure racial equity in the District, the legislation creates a racial impact assessment requirement for council legislation. The District’s Council Office of Racial Equity (CORE) is charged with evaluating legislation prior to committee markup for its potential impact on racial equity.
States are taking important steps to immediately address the impact of COVID-19 on racial and ethnicity disparities and incorporating health equity approaches into their systems moving forward. In their 2021 state of the state addresses, 21 governors highlighted strategies to address racial and ethnic disparities. Several governors specifically discussed racism and racial injustices, citing how communities of color were disproportionately impacted by COVID-19 and articulating their commitment to improvement. The recent passage of the American Rescue Plan will provide significant financial support to states for their recovery efforts. States have the opportunity to center equity in their dispersal of funds and address the health, social, and economic impact of COVID-19.
To read more about state initiatives to address health equity, explore NASHP’s toolkit, Resources for States to Address Health Equity and Disparities.
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.
Across the Nation, State Leaders Are Tackling the Global Issue of Environmental Protection
The profound connection between the environment and human health makes headlines primarily when things go wrong: when air pollution triggers asthma attacks, water is tainted by toxins, and tick- and mosquito-borne diseases spread, propelled by a changing climate. But some state leaders see the health of the environment as a critical and continuous state policy priority.
A recent analysis by the National Academy for State Health Policy (NASHP) showed that at least half of the nation’s governors called for environmental protection measures in their 2019 inaugural or state of the state addresses. In addition, 23 state governors signaled their commitment to addressing climate change by joining the US Climate Alliance. Clean water, climate change, and clean and renewable energy goals topped the list of environmental priorities articulated by governors across the country. For example, the governors of Maine and Florida both addressed the environment in their speeches:
- Maine Gov. Janet Mills: “The Gulf of Maine is warming faster than almost any other saltwater body in the world, driving our lobsters up the coast. Our coastal waters are growing acidic, temperatures are fluctuating, and sea levels are rising, endangering our shellfish industry. Our forests are less suitable for spruce and fir and more suitable for ticks. Climate change is threatening our jobs, damaging our health and attacking our historic relationship to the land and sea.”
- Florida Gov. Ron DeSantis: “Our economic potential will be jeopardized if we do not solve the problems afflicting our environment and water resources. …We will fight toxic blue-green algae, we will fight discharges from Lake Okeechobee, we will fight red tide, we will fight for our fishermen, we will fight for our beaches, we will fight to restore our Everglades and we will never ever quit, we won’t be cowed and we won’t let the foot draggers stand in our way.”
State leaders are also taking action on concerns about the environment and climate change through executive orders and budget and legislative proposals. Here is a snapshot of some recent actions state leaders have taken.
Executive Orders
A number of new governors have issued executive orders that seek to address climate change, protect clean air or water, and protect residents from toxins:
- Colorado Gov. Jared Polis issued Executive Order B 2019-002, “Supporting a Transition to Zero Emission Vehicles.”
- Florida Gov. Ron DeSantis issued Executive Order 19-12, “Achieving More Now for Florida’s Environment,” which directs the state departments of environmental protection, health, and economic opportunity to protect the state’s water resources through a range of actions, including “adamantly oppos[ing]” all off-shore oil and gas activities, including fracking.
- Florida is not the only state concerned with extraction off its coastline: South Carolina Attorney General Alan Wilson filed a motion on Jan. 7, 2019, to block seismic testing and drilling off South Carolina’s coast. The state joined a lawsuit against the federal government filed by some of the state’s local governments and the South Carolina Small Business Chamber of Commerce.
- Maine Gov. Janet Mills’ executive orders include 5 FY 19/20, “An Order to Study the Threats of PFAS [Per- and polyfluoroalkyl] Contamination to Public Health and the Environment,” which creates a task force to study the risks posed by certain industrial chemicals that have been found in water and soil. Executive Order 3 FY 19/20, “An Order Concluding the Maine Wind Advisory Commission and Wind Permit Moratorium,” ends a moratorium that had prohibited the state from considering new wind turbine permits.
- New Mexico Gov. Michelle Lujan Grisham issued 2019-003, an “Executive Order on Addressing Climate Change and Energy Waste Prevention,” which establishes a Climate Change Task Force. It also directs all state agencies to evaluate the impact of climate change on their operations and integrate into their programs strategies to mitigate climate change.
- Virginia Gov. Ralph Northam’s executive orders include “Increasing Virginia’s Resilience to Sea Level Rise and Natural Hazards,” which directs state agencies to plan for increases in extreme weather and natural disasters attributable to climate change.
Legislation
Some state legislators across the country are introducing bills designed to protect the environment by promoting clean or renewable energy. A small sample of the bills include the following:
- Colorado’s HB 19-1261, “Climate Action Plan to Reduce Pollution,” would establish greenhouse gas reduction targets, and specify considerations for the state air quality commission to take into account when setting rules and policies to reduce greenhouse gasses. At the time of writing, the bill was awaiting the governor’s signature.
- Maine Gov. Janet Mills signed “An Act to Prohibit the Use of Certain Disposable Food Service Containers,” which bans single-use food containers made of polystyrene, which is also referred to as Styrofoam. She also signed LD 216, which protects water quality in shoreland areas.
- Maryland Gov. Larry Hogan signed the Clean Cars Act of 2019 (HB 1246), which expands the tax credit for purchasing electric vehicles, and doubles the funding for the program to $6 million.
- In Nevada, Gov. Steve Sisolak signed SB358 into law on Earth Day. It requires that 50 percent of electricity generated, acquired, or saved by 2030 come from renewable sources or efficiency measures.
- Virginia Gov. Ralph Northam signed SB 1355 “Coal Combustion Residuals Impoundment; Closure,” into law on March 19, 2019. It requires owners or operators to close coal ash ponds at certain locations within the Chesapeake Bay watershed.
Budget Proposals
A number of state budget proposals aimed to ensure funding for the environmental priorities governors outlined in their speeches. A small, non-representative sample of these proposals includes:
- The Florida budget, which was awaiting the governor’s signature at the time of writing, includes $682 million to protect the state’s water resources, including Everglades restoration, according to the chair of the House Agriculture and Natural Resources Appropriations Subcommittee.
- Maryland’s enacted budget includes a $20.2 million special fund appropriation for renewable and clean energy programs and incentives, and requires reporting on Chesapeake Bay restoration efforts.
- Utah legislators appropriated more than $28 million for air quality initiatives, according to the state’s department of environmental quality.
- The Wisconsin executive budget act (SB 59), pending at time of writing, would increase general obligation bond authority for the Safe Drinking Water Loan Program for municipal drinking water infrastructure, and for the Clean Water Fund Program, which funds local government pollution and sewage projects.
Cross-Agency Environmental Initiatives
A number of states are establishing environmental task forces or committees that draw on the expertise of a number of agencies and disciplines within each state:
- Florida’s Executive Order 19-12 calls for a Blue-Green Algae Task Force.
- Maine introduced LD 1284/HP 926, “An Act to Create the Science and Policy Advisory Council on the Impact of Climate Change on Maine’s Marine Species.”
- New Mexico’s Executive Order 2019-003 established an interagency Climate Change Task Force.
- Virginia’s Executive Order 29 established the Virginia Council on Environmental Justice.
- Wisconsin established the Speaker’s Task Force on Water Quality.
These examples demonstrate how states are taking concrete policy steps to further environmental protection agendas. They also illustrate how states can use their policy levers to tackle one of the thorniest health issues facing states, the nation, and the world.
This is the first in a series exploring how state leaders can improve the upstream factors affecting health, such as clean air, safe housing, and quality early education.
This series is produced in partnership with the de Beaumont Foundation.
States Take Administrative Actions to Curb Medicaid Drug Costs
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During the 2018 legislative session, 28 states passed 45 laws to curb the rising cost of prescription drugs. In addition to legislative solutions, states are taking administrative action to better manage state spending on Medicaid pharmacy benefits. Ohio, West Virginia, and Vermont offer examples of states taking innovative administrative approaches to rein in drug costs.
Ohio Medicaid Replaces Spread Pricing with More Transparency
In August, the Ohio Department of Medicaid announced it would require its five managed care plans to end contracts with pharmacy benefit managers (PBMs) that used “spread pricing.” Spread pricing is a payment model that allows PBMs to profit by charging insurance plan sponsors more for a prescription than the PBM pays the dispensing pharmacy. The lack of transparency in the spread-pricing model makes it difficult for states to identify how much spread pricing contributes to their overall drug costs.
Ohio investigated the impact of spread pricing and found it generated an 8.8 percent PBM markup on its Medicaid managed care pharmacy claims, a margin that enabled PBMs to pocket an average of $5.70 per prescription dispensed. In response, starting Jan. 1, 2019, Ohio will require managed care plans to use a transparent, pass-through payment model that requires PBMs to charge Medicaid exactly what they pay the dispensing pharmacy. To compensate PBMs under this pass-through pricing model, Medicaid managed care plans will pay PBMs an administrative fee estimated at 95 cents to $1.90 per prescription. To meet the deadline, managed care plans are working with PBMs to restructure contracts to comply with the pass-through requirement.
In contrast to Ohio’s administrative approach, Louisiana’s 2018 spread pricing law, Act 483, bans PBMs that contract with the state from retaining any revenue in excess of the amount the PBM paid to the pharmacy through spread pricing.
West Virginia Ends Use of PBMs
In 2017, West Virginia stopped using PBMs altogether after an audit revealed that public employee health plans were charged 1 percent more for prescription drug claims than PBMs were paying pharmacies. Lawmakers determined the 1 percent cost the state $10 million per year.
Instead of using PBMs to administer pharmacy benefits for state workers and Medicaid beneficiaries, West Virginia now acts as its own PBM under a fee-for-service model run by its Bureau for Medical Services’ Office of Pharmacy Services (OPS). In addition to managing the single state preferred drug list, which had previously been used across managed care plans, OPS developed a Preferred Diabetes Supply List. The state pharmacy board estimates that carving out pharmacy benefits from its Medicaid managed care program will save the state $38 million in the first year. Administrative cost savings and modifications to dispensing cost formulas helped achieve those savings.
Vermont Explores a Direct Relationship with a Wholesaler
The Department of Vermont Health Access (DHVA) released a Request for Information (RFI) in September to explore potential savings from establishing a direct relationship with a drug wholesaler. The RFI was in response to a legislative mandate in Act 193 that requires the state to identify opportunities for saving in the prescription drug supply chain. Under this model, payment for drugs would flow directly from DHVA to the wholesaler. Currently, pharmacies purchase drugs directly from wholesalers and are then reimbursed by DHVA. All publicly-funded prescription benefits in Vermont are reimbursed under a fee-for-service model, and pharmacy reimbursement rates are set by the state, not a pharmacy benefit manager. As a result, DHVA makes all payments to pharmacies directly, and not through a third party.
A direct relationship between a wholesaler and the state would allow DHVA to purchase drugs in a manner similar to the 340B Drug Pricing Program model, which may present savings opportunities. DHVA must report its findings to the Vermont legislature by Nov. 15, 2018.
Recent action, both administrative and legislative, reflects states’ growing demand for more transparent pricing and payment models. Learn more about all state action on curbing drug costs at the National Academy for State Health Policy’s Center for State Rx Drug Pricing, a warehouse of resources, including model legislation, new state laws, and legal analysis.
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. 
