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2022 State of the State Addresses Reflect Realities of Health, Economic Recovery
/in Health Coverage and Access Blogs Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Featured Policy Home, Health Coverage and Access, Health System Costs, Maternal, Child, and Adolescent Health, Population Health, Prescription Drug Pricing /by Allie Atkeson, Anita Cardwell, Clare Cartheuser, Rebecca Cooper, Gia Gould and Elinor HigginsGovernors use their annual state-of-the-state addresses to showcase successes and accomplishments over the past year and to define their policy priorities for the year ahead. This year 36 states will hold gubernatorial elections, so many governors use their state-of-the-state addresses to build their case for reelection and visions for the future. By late February, 41 governors had delivered speeches outlining plans to address a wide variety of health and economic related issues in the coming year, as the immediate health-related emergency of the COVID-19 pandemic has faded. Most governors reflected on the incredible response from frontline responders and public health agencies’ ability to meet the needs of the crisis but focused their future plans on how to emerge from the pandemic and respond to the economic and mental health crises that remain.
View a map highlighting governors’ goals on a variety of health-related policies here.
Priorities diverged from their 2021 health care and social determinants priorities. While many governors continued to address social drivers of health, citing affordable housing and access to healthy food and the environment as key levers to improve health, more highlighted livable wages, support for the workforce and business, and education. Notably, in comparison to last year, many more governors highlighted the need to address health care workforce shortages that have been exacerbated by the COVID-19 crisis. Governors also mentioned their priorities for investing American Rescue Plan Act (ARPA) funding.
These issues do not exist in isolation; many of these topics, including mental health, education, workforce, and equity, are woven throughout the speeches and require a whole-of-government approach to address. Below are highlights from key themes that the governors addressed.
Behavioral Health
Twenty-eight governors discussed behavioral health in their speeches this year, up from 22 last year. With an increased focus on crisis services, substance use disorder services and school-based mental health care as a result of COVID-19, governors addressed the need for investments in behavioral health services and workforce.
Fourteen governors mentioned making significant investments in behavioral health in their state-of-the- state addresses. In Idaho, Gov. Little proposed accelerating the implementation of the Behavioral Health Council’s recommendations, including a $50 million dollar investment in behavioral health care. In the executive budget, Gov. Lujan Grisham of New Mexico is proposing “tens of millions of dollars into new behavioral health services, expanding access to treatment for substance abuse, suicide interventions and more. New Mexicans call me about this issue more than almost any other, and we will answer that call.”
Ten governors mentioned substance use disorder, including the opioid epidemic and recent rises in overdoses over the past year. New Jersey Gov. Murphy discussed the state’s data driven approach to the opioid-use epidemic and expansion of harm reduction centers and naloxone.
In Delaware and Tennessee, governors discussed their executive branch efforts to combat the opioid epidemic. In Delaware, the Behavioral Health Consortium is led by Lt. Gov. Hall-Long, and the state was one of a few to see a decrease in the rate of overdose deaths. In Tennessee, Attorney General Slatery is working to deploy funding from the $26 billion dollar suit against pharmaceutical companies. Governors in Alaska and Missouri discussed providing behavioral health services to individuals in the criminal justice system.
Nine governors referenced youth behavioral health and school-based services now that children are back in the classroom. In Alabama, Michigan, Vermont, Washington, and Wisconsin, governors proposed additional school mental health supports. Gov. McMaster in South Carolina stated, “we must also recognize that a mental health crisis exists in South Carolina, especially among our young people who have weathered two years of disruptions, virtual instruction, isolation, and constant changes to normal routines.” He also directed the Health and Human Services Director to study the state’s behavioral health system as 60 percent of South Carolina children are enrolled in Medicaid. In Washington, Gov. Inslee’s budget will increase the number of school counselors, nurses, psychologists, and social workers in schools.
Six governors discussed strengthening the crisis system of care in their states through outreach services, mobile unitsand new centers. Gov. Ivey of Alabama proposed funding for two new mental health crisis centers and in New Hampshire, Gov. Sununu discussed mobile crisis support and a new 24/7 crisis call center. Alaska Gov. Dunleavy announced reopening the unit that serves adolescents in crisis, and additional funding for staffed beds.
Six governors also discussed supporting the behavioral health workforce through crosscutting investments. Massachusetts Gov. Baker discussed working with the legislature to address “enormous staff and clinician shortages in exactly the areas of care that we need most.” In Michigan, Gov. Whitmer stated, “40 percent of Michiganders do not get treatment for their mental illness. We will address this shortfall by expanding Michigan’s Loan Repayment Program for mental health professionals. And we will make a historic investment to retain and recruit hundreds more mental health workers.”
Broadband
This year, 17 governors discussed broadband in their state-of-the-state speeches, down from 30 in 2021. Governors in four states, Alabama, Delaware, Hawai’i and Maine proposed leveraging ARPA funding to support broadband efforts in their states. Other themes included broadband connectivity to support remote work and education and the creation of statewide authorities for broadband. Missouri Gov. Parson requested a “$34 million dollar investment in rural communities to increase access to telehealth and telemedicine services.”
Five governors identified broadband as critical for supporting remote work and education. According to Kansas Gov. Kelly, hotspots were deployed to students in low-income households to continue their education remotely. Gov. Dunleavy in Alaska stated that broadband “…unlocks the opportunity for us to live anywhere and work from anywhere in this Great State.”
Additionally, governors in Kansas and Maine are establishing statewide broadband authorities, In Kansas, the Office of Broadband Development has expanded internet access to over 50,000 new households and businesses. The Maine Connectivity Authority is “a new entity charged with achieving universal internet access.”
COVID-19
In 2021, 34 governors addressed COVID-19 in their state-of-the-state speeches, emphasizing vaccine distribution and economic recovery. In 2022, 17 governors mentioned COVID-19 with a focus on COVID-19 mandates, return to school, testing and vaccines.
The continued rollout of vaccines and testing as a strategy to mitigate the spread of COVID-19 were discussed by 12 governors. Gov. Sununu in New Hampshire emphasized the importance of data guiding the state’s approach. In South Dakota, Gov. Noem mentioned the state’s free at-home test program and announced an additional 1 million new tests to be delivered throughout the state.
Four governors spoke against COVID-19 mandates, including vaccines and masking. Gov. Dunleavy of Alaskastated his administration, “will continue to defend Alaskans’ rights to make their own medical decisions about vaccines and therapeutics for themselves and their families in consultation with their doctors and pharmacists.” Similarly, Gov. Parson of Missouri said, “when it comes to COVID-19 mandates, I firmly believe that the people should have say through their local elected representatives and not be dictated by needless executive action or any one person.”
Return to in-person instruction and masks in schools were discussed by three governors. Recently elected Gov. Youngkin of Virginia signed an executive order that allows parents to opt out of mask mandates in schools. In Kentucky, Gov. Beshear discussed the strategy to prioritize vaccines for educators and the state’s ability to return to in-person instruction in every school district early on.
Education
Thirty-seven governors discussed education this year and the impacts of COVID-19 were present throughout the speeches. Major themes included teacher recruitment and retention, addressing learning loss, and affordability of higher education. There was a marked decrease compared to last year in the number of governors that talked about expanding access to early education. Twenty-three governors proposed generalized investment in schools and students, and five governors emphasized the importance of keeping children in the classroom. Gov. Ige of Hawai’iemphasized the importance of in-person learning, but also announced the launch of the Hawai’i Virtual Learning Network—a virtual classroom network that can supplement in-person classes.
Eighteen governors talked about recruiting and retaining qualified teachers, with a major focus on increasing teacher salaries and recognizing the difficulties that educators have faced over the past two years. Gov. DeSantis of Florida proposed increases in teacher salaries in addition to $1000 bonuses for the second year in a row. Some governors also mentioned other types of support for teachers. For example, Gov. Hochul of New York proposed more “effective training and support, faster and easier certification, and stronger career pipelines and ladders”.
Sixteen governors proposed targeted investments in improving the quality of education in their states by enhancing literacy levels and meeting benchmarks, supporting greater investment in STEM education, or by making up learning loss sustained during the COVID-19 pandemic. Gov. Burgum of North Dakota talked about setting computer science and cyber science graduation standards for K-12 students, undergraduate students, and graduate students. Indiana Gov. Holcomb talked about the continued investment in accelerated learning programs to support students who fell behind during the pandemic.
Many governors also focused on opportunities following K-12 education, whether entering the workforce, enrolling at a community college, or attending a four-year university. Ten governors talked about apprenticeship programs and adult education opportunities, fourteen proposed investments in higher education, with nine of those focusing specifically on community college investments, and sixteen governors proposed higher education affordability measures like tuition freezes, scholarships, or loan forgiveness programs.
Ten governors also emphasized parental choices and roles in education, through vouchers, school choice programs, charter schools, or more parental involvement in curriculum. Idaho Gov. Little proposed an investment in Empowering Parents grants, which would cover “computers, tutoring, internet connectivity and other needs so students have the best chance for success.”
Equity
COVID-19 clearly shone a light on racial and ethnic health and economic-related disparities that existed prior to the pandemic, and in 2022, 9 governors highlighted the connection to equity in their plans, down from 21 governors in 2021. Three governors discussed the connection and disproportionate impact of the environment on low-income communities and communities of color. Oregon Gov. Brown used an equity lens to set the tone of her speech. She noted that she is “…most proud of is how Oregon approaches … challenges––through an equity lens. With a focus on our communities hardest hit by climate change: rural communities, people with low incomes, and people of color.”
Delaware Gov. Carney announced that the state, with federal support, will invest more than $400 million in Delaware’s clean water infrastructure, focusing on underserved communities. New York’s Gov. Hochul also proposed work to fix longstanding problems that disproportionately impact communities of color, including reconnecting neighborhoods that were cut off by highways, and directing the Metropolitan Transit Authority (MTA) to conduct an environmental review, to ensure no further harm is done.
Three governors also considered the intersection of poverty and communities of color and developed strategies to mitigate economic impacts.
Health Care Costs
Seven governors addressed increasing health care costs— emphasizing the need to alleviate the burden of rising healthcare costs on both individuals and state budgets. Notable state efforts to lower costs across the health care system include:
– New Jersey Gov. Murphy committed to lowering healthcare and prescription drug costs through a cost growth benchmark and additional transparency requirements throughout the prescription drug supply chain to identify cost drivers.
– Nevada Gov. Sisolak announced that the state will join the Northwest Prescription Drug Consortium with Washington and Oregon to leverage collective purchasing power to lower the cost of prescription drugs.
– Gov. Cox of Utah asked legislators to support the newly established Utah Sustainable Health Collaborative tasked with developing strategies to lower health care costs while improving outcomes.
Virginia Gov. Youngkin expressed support for legislation to extend access to association health plans, providing small business owners with a lower cost coverage option for their employees. Three governors celebrated successful state reforms which have lowered health insurance costs in the individual and small group market.
– Colorado Gov. Polis shared that the state reinsurance program reduced healthcare premiums by 24 percent on the individual market, with even more significant cost savings in the western region of the state.
– Following last year’s launch of a state-based marketplace, New Jersey Gov. Murphy shared that enrollment in the individual marketplace increased by more than 25 percent.
– Nevada Gov. Sisolak touted last year’s adoption of a public option to increase affordability and expand coverage options.
Five governors addressed the issue of rising prescription drug costs, with the majority focusing on the prohibitively high cost of insulin. Governors in Michigan and Colorado aim to improve insulin affordability through monthly price caps and Gov. Whitmer of Michigan announced that the state’s Attorney General would launch an investigation into one of the largest producers of insulin for excessive pricing.
Health Care Workforce
This year, against the backdrop of ongoing COVID-19 hospitalizations and concerns about burnout, 20 governors talked about their plans to address workforce shortages and bolster the health care workforce. In 2021, only eight governors mentioned plans to support or bolster the healthcare workforce. Recruitment was the overarching theme this year, with fifteen governors talking about how to successfully train more nurses, doctors, or emergency responders, how to use scholarships or loan forgiveness programs to incentivize entry into the health care field, and how to bring more health care providers into the state from elsewhere. Governors of New York, South Dakota, and Vermont talked about recognizing out of state licenses to attract qualified providers to their states. In Alaska, Georgia, Hawai’i, Maine, New Mexico, and Oklahoma, governors talked about expanding education programs to train more nurses and other health care providers. These proposals included plans for adding faculty to existing programs, opening new educational programs, and admitting more students to increase the number of graduates. Gov. Reynolds of Iowa announced a new apprenticeship program for high school students that would allow them to become certified nursing assistants before graduating high school. And governors in Iowa, Illinois, Rhode Island,and New York mentioned plans to offer additional scholarships, tuition reimbursement, or loan forgiveness for students training to enter the health care workforce—particularly if they stay in-state after graduating.
In addition to recruitment, nine governors also focused on strategies to retain the existing workforce—particularly those individuals who are experiencing the exhaustion of the COVID-19 pandemic. In Alabama, Colorado, Maine, New York, and Wisconsin, governors talked about increased compensation for those in the healthcare field, through pay raises, higher Medicaid reimbursement rates, or bonuses. Gov. Polis of Colorado and Gov. Pritzker of Illinoismentioned plans to wave licensing fees for healthcare providers in their states.
Housing and Homelessness
Sixteen governors addressed housing and homelessness in their state of the state speeches. Highlighting the impact of the COVID-19 pandemic, governors concentrated on the need to increase the supply of affordable housing, strategies to reduce homelessness, and rent and mortgage assistance. In her speech, Gov. Brown in Oregon made the connection between housing and homelessness stating, “there is no avoiding the fact that these two issues are undeniably linked –– a lack of affordable housing and some of the highest rates of people experiencing homelessness. In Oregon, today, missing one paycheck can be the difference between going to bed in a home with heat and running water, or sleeping unsheltered.”
Eleven governors spoke for the need to increase the housing stock with an emphasis on affordable housing. Gov. Mills of Maine referenced the Maine Jobs and Recovery Plan which will invest $50 million to “increase the number of energy-efficient, affordable homes for working Maine people.” In Colorado, Gov. Polis announced 14,000 units of affordable housing have been developed in the past year, saving families more than $72 million annually.
Governors in Delaware, New Mexico and Oregon discussed providing rent and mortgage assistance to residents, and governors in Colorado, Delaware and New Hampshire addressed using ARPA funding to support their housing programs. New Mexico Gov. Lujan Grisham said, “in the next 12 months your state government is going to deliver an additional $230 million in rent and utility assistance to the New Mexicans who need it most.”
In addition to increasing the housing supply, five governors discussed reducing homelessness in their states, proposing models such as permanent supportive housing. In Colorado, Gov. Polis proposed several interventions to address homelessness including “affordable and transitional housing, substance use treatment and recovery care, related residential programs, and permanent housing with wrap-around support services, and recipients of funds need to be held accountable for actually reducing homelessness.” Gov. Hochul of New York identified root causes of homelessness in her speech—poverty, addiction and housing insecurity—and announced a five-year housing plan to preserve 100,000 affordable homes with supportive services in 10,000 units.
Jobs/Livable Wages
The topic of employment, workforce investments, livable wages and the need to support overall economic growth was mentioned by a total of 38 governors, which is an increase from last year when 28 governors focused on this topic.
The most common theme was planned investments to promote workforce development through new training initiatives. Governors in Maine, Oklahoma, South Carolina, Tennessee and Vermont specifically mentioned apprenticeship opportunities and career development for adolescents and young adults, and Vermont’s Gov. Scott placed an emphasis on trades training, in particular to help grow the number of nurses and other healthcare workers in the state. Oregon’s Gov. Brown discussed plans to build upon Future Ready Oregon, a workforce training initiative focused on jobs in health care, technology, manufacturing, and construction. She also mentioned plans to incorporate support services to help individuals advance from an entry-level job such as a certified nursing assistant to a health care administrator. Governors in Delaware, Michigan, Mississippi, and South Carolina shared plans to invest recently allocated federal funds to support workforce skills training initiatives, and Hawai’i’s Gov. Ige highlighted the launch of an online hub designed to connect unemployed individuals with career and training opportunities.
Governors also focused on the issue of supporting overall economic development. Delaware’s governor highlighted the state’s focus on championing small businesses to bolster job growth, including both “mom-and-pop” small businesses as well as cutting-edge technology companies, and Gov. Murphy of New Jersey commented similarly about supporting both technology start-ups and traditional small businesses. Other governors spoke about the role of planned tax cuts with the intention of supporting job creation, with governors in Colorado, Idaho, and Indiana mentioning this issue.
Some governors also focused on the issue of wages and highlighted plans to increase pay rates for state employees, such as law enforcement and teachers. The governors of Alabama, Kentucky and Missouri announced pay raises for all state workers, and Gov. McMaster commented that while overall compensation for South Carolina state employees should be reevaluated, salary increases should be determined by merit-based performance incentives rather than an across-the-board pay raise. Proposals to increase salaries for teachers specifically were raised by the governors in Alabama, Florida, Georgia, Mississippi, Oklahoma, South Carolina, and Tennessee. Additionally, the governors of both Delaware and Pennsylvania advocated for an increase in the overall minimum wage in their states. Gov. Wolf noted that when factoring in inflation, minimum wage workers in Pennsylvania actually experienced a $2 pay reduction.
Medicaid, Coverage and Access
Despite the significant growth in state Medicaid programs during the pandemic, only five governors mentioned Medicaid in their speeches.
Several governors proposed Medicaid coverage and benefit expansions. In response to rising maternal mortality rates, governors in Georgia and Rhode Island advocated for extending postpartum Medicaid coverage from 60 days to 12 months to provide coverage continuity during the critical postpartum period. Rhode Island Gov. McKeeintroduced a proposal to cover all kids regardless of immigration status through the state’s Medicaid program. Tennessee Gov. Lee announced a $25 million dollar investment to broaden access to dental services for over 600,000 Medicaid recipients as well as an additional $55 million to support the Medicaid Pathways to Independence program.
Only Kansas Gov. Kelly advocated for adoption of Medicaid expansion, providing the economic argument that, “Medicaid expansion won’t just protect small towns and their residents, it will keep health care professionals from moving to neighboring states… (without Medicaid expansion) we are sabotaging our rural communities and their efforts to recruit new jobs and residents”.
The broader topic of health coverage and access was mentioned by governors in six states — a significant decline from last year when 17 governors addressed these issues. Governors were largely focused on the need to improve rural health care access:
– New Mexico Gov. Lujan Grisham proposed the creation of a Rural Health Care Delivery Fund to provide support for health systems in counties with fewer than 100,000 residents. The fund would provide financial support for newly constructed hospitals in rural areas to compensate for operating losses incurred during the first five years of operation.
– South Dakota Gov. Noem aims to improve health care options for rural communities by extending telehealth flexibilities to emergency responders.
– Wyoming Gov. Gordon committed to improving care accessibility through improvements to the state’s Emergency Medical System.
– Gov. Evers of Wisconsin will invest $20 million to provide rural communities with flexible funding to increase staffing support and provide additional training to first responders.
Gov. Pritzker of Illinois commented on the state’s recent $3.8 billion dollar investment in hospitals serving high proportions of Medicaid patients to improve care in underserved communities.
Other health-related issues
Below is a snapshot of some of the other health-related topics that governors mentioned:
- Aging: Four governors mentioned issues related to the elderly population in their speeches. Mills of Maine announced plans to establish a Silver Cabinet (similar to the state’s Children’s Cabinet) to promote interagency action on long-term care issues. New Mexico’s governor proposed an initiative called New Mexi-Care to expand an existing state program that supports and reimburses caregivers for the care they provide to elderly family members, regardless of Medicaid eligibility. Also, although New York’s Gov. Hochul did not mention the topic of aging in her speech, in an accompanying document she outlined intentions to develop a state master plan for aging.
- Child Care and Family Supports: Nine governors commented on proposals to support the needs of families, such as Delaware’s Gov. Carney advocating for paid leave in the private sector as well as other governors promoting increased access to high-quality and affordable child care. Maine’s Gov. Mills noted plans to include $12 million in the state’s supplemental budget to increase child care workers’ wages, and also highlighted the use of American Rescue Plan Act funds to strengthen the state’s child care system, which includes stipends for child care workers as well as investments in child care facilities and early childhood education programs. Iowa’s Gov. Reynolds announced an expansion of the state’s Childcare Challenge, which is designed to increase access to child care options for families, and commented on progress in implementing recommendations from the state’s Child Care Task Force. North Dakota’s Gov. Burgum highlighted a new initiative that will be launched in the spring to help employers offer child care benefits to their employees and a soon-to-be finalized comprehensive state strategy for increasing access to high-quality, affordable child care. Utah’s Gov. Cox proposed creating a new government position to address the needs of parents and children, which will focus on parental leave, increased access to child care, and mentoring opportunities for parents. Also, Tennessee’s Gov. Lee highlighted recent funding for the state’s Healthy Starts Initiative, which focuses on maternal health and holistic care for both mothers and children.
- Child Welfare: Eight governors spoke about the child welfare system, including the governors of Arizona, Florida, Georgia, and Tennessee who mentioned potential new investments to support caregivers. Ducey in Arizona mentioned plans to provide resources to extended family members caring for children who would otherwise be in the foster care system, and Georgia’s governor proposed a 10 percent provider rate increase for all foster parents, relative caregivers, and child caring and placing agencies. In Washington, Gov. Inslee said that his budget would include $80 million to support foster care youth with complex needs and help them transition out of foster care. Gov. Kelly noted that Kansas was one of the first states to implement the Family First Prevention Services Act and the recent creation of the Division of the Child Advocate to help ensure that youth in the child welfare system are healthier and safer.
- Environmental Actions: Seventeen governors discussed their plans to protect the environment, including plans to address climate resiliency and ensuring clean air and water for residents. Ten governors discussed plans to improve water quality. Kansas shared the state’s new water plan, a five-year blueprint to ensure the state has a reliable, quality water supply to support the needs of Kansas communities, including their farming economy. Ten governors discussed their plans to address climate change and promote climate resiliency. Delaware’ Gov. Carney announced the state’s new Climate Action Plan. Six governors discussed actions to reduce carbon emissions or become carbon neutral, and four governors noted deadlines by which this must occur. Ige reflected that Hawai’i was the first state to commit to a net-negative goal by 2045 and re-committed to doubling down on this effort.
- Food Access: Eight governors commented on the issue of food security, distribution, and production. Alaska’s Gov. Dunleavy spoke about plans to create a Food Security Task Force to help promote the state’s agriculture and mariculture industries and minimize disruptions in the food supply chain by supporting state-grown products. In response to rising food costs, governors in both Illinois and Kansas advocated that their state’s grocery taxes should be suspended, and Utah’s governor proposed a $160 million grocery tax credit for families. Maine’s Gov. Mills announced that her proposed budget will include plans to fund universal free meals in schools and promote school and community gardens.
- Public Health: Three governors addressed the topic of public health, with the governor of Indiana mentioning a number of public health issues, including that the state’s Public Health Commission will be publishing recommendations on ways to modernize and strengthen the state’s overall public health system. Also, given that the state ranks 46th in obesity, 46th in smoking, and 40th in childhood immunizations, he emphasized the importance of investing in preventive measures to minimize future costly health complications. Additionally, he noted plans to continue focusing on reducing infant mortality and strengthening childhood lead screening efforts. Nebraska’s Gov. Ricketts highlighted plans to use $200 million from the American Rescue Plan Act for public health emergency response efforts. South Carolina’s governor also noted plans to use federal funds for investments in upgrading water and sewer systems and commented on how these enhancements can improve the overall public health of communities.
- Transportation: Seven governors spoke about transportation infrastructure investments from a health-focused perspective. Five governors mentioned initiatives to support clean transportation, with Delaware’s Gov. Carney and Michigan’s Gov. Whitmer highlighting plans to dedicate resources to support electric vehicles and Washington’s Gov. Inslee proposing to invest nearly $1 billion to fund a range of transportation programs that reduce pollution. Additionally, Indiana’s Gov. Holcomb spoke about investing in commuter rail projects as well as committing $150 million to expand the state’s walking, hiking, and biking trails.
- Violence Prevention: Thirteen governors commented on the issue of violence prevention. The governors of Delaware, Maryland, New Jersey, and New York emphasized the importance of gun violence prevention, and the governors of both Colorado and Illinois focused on community-based violence prevention initiatives. Alaska’s Gov. Dunleavy requested state legislators to fund the People First Initiative, which includes addressing the issues of domestic violence and sexual assault, human trafficking, and missing and murdered Indigenous individuals.
Conclusion
As the United States enters the third year of the pandemic, governors’ 2022 state-of-the-state speeches reflect the realities of health and economic recovery. Compared to 2021, states have access to additional resources through ARPA, and their priorities remain centered on addressing the lasting impacts of the COVID-19 pandemic with an emphasis on behavioral health, education and jobs and wages. As state legislatures convene and enact budgets, the National Academy for State Health Policy will continue to track many of these topics in the coming months.
Michigan’s Caring for Students Program Leverages Medicaid Funding to Expand School Behavioral Health Services
/in Policy Michigan Blogs, Featured News Home Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health /by Anita Cardwell and Gia GouldDespite a federal rule change that allows states to bill Medicaid for school-based physical and behavioral health services provided to all Medicaid-enrolled students, many states struggle to overcome the persistent and complex billing challenges associated with receiving Medicaid reimbursement for delivery of these critical services.
To access additional Medicaid funds to expand school-based behavioral health services, Michigan established the Caring 4 Students (C4S) program, which strengthens partnerships between its Medicaid agency, providers, and educational entities and streamlines Medicaid billing policies and procedures. This case study explores how Michigan overcame some of the challenges states face when seeking Medicaid reimbursement for school-based behavioral health services. It also describes how Michigan retooled the C4S program during the pandemic to ensure the services continued to reach students through telehealth.
Introduction
The majority of children who receive behavioral health care access these services in school settings. According to the School-Based Health Alliance, 70 percent of children who receive mental health services access them at school.[1] As an increasing number of children experience worsening behavioral health due to the pandemic,[2] the need for these support services is even greater. Also, with the pandemic forcing many schools to offer reduced in-person teaching or fully remote learning, they have had to adapt and provide more behavioral health services through telehealth.
While states can fund school-based behavioral health services in a variety of ways, a number of states have leveraged federal Medicaid dollars to help fund behavioral health services for students with Medicaid coverage. In federal fiscal year 2016, estimated Medicaid spending for both school-based and administrative services totaled $4.5 billion.[3]
Historically, schools were restricted in their ability to receive federal Medicaid reimbursement for physical and behavioral health services provided to Medicaid-enrolled students. The “free care rule” prohibited schools from seeking Medicaid payments for services provided to Medicaid-enrolled students if the services were provided for free to all students, such as no-cost health screenings. While the rule contained an exception for services identified in Medicaid-enrolled students’ Individuals Education Plans (IEPs), it limited schools’ ability to obtain Medicaid reimbursement for services provided to students with Medicaid coverage who did not have IEPs. However, as a result of the “free care rule” policy reversal in 2014, states have the opportunity to bill Medicaid for physical and behavioral health services delivered to all Medicaid-enrolled students, including students without IEPs.
Despite the rule change, some schools still face challenges in obtaining Medicaid reimbursement for services provided to Medicaid enrollees, either due to state-level policy barriers or other issues, such as the administrative complexity of the billing process. School staff often may not have the expertise or resources to implement Medicaid billing procedures, and often need assistance and training from state education and Medicaid agencies.[4] Also, some states with budgets impacted by the pandemic may be limited in their ability to invest in an expansion of services.
Development of C4S
To help increase students’ access to behavioral health services, in 2019 Michigan capitalized on the flexibility provided by the reversal of the free care rule by creating the C4S program through a state plan amendment (SPA) that leverages the Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) benefit. Through the C4S program, Michigan schools can now receive Medicaid reimbursement for services delivered to Medicaid-eligible students if they are covered under EPSDT, delivered within a provider’s scope of practice, and billed in accordance with state Medicaid billing procedures.[5]
In addition to federal Medicaid dollars, implementation of the C4S program was bolstered by state funding,[6] which included a $16.5 million allocation by the state legislature in the fall of 2018 to provide direct medical services to students that must be billed to Medicaid whenever possible. State officials subsequently acted quickly to submit a Medicaid SPA by December 2018, and after approval by federal officials, the state launched the C4S program in October 2019.
Interagency Coordination
Nearly all 587 school districts in Michigan fall under the authority of an intermediate school district (ISD), which conducts various administrative functions for the schools. Michigan has 56 ISDs, as well as two independent school districts, and the ISD system structure allows all schools, regardless of how small they are, to participate in the C4S program because the reimbursement claims are administered by the ISDs. The state considers the ISDs to be the main provider entities within the C4S program, as clinicians participating in the program report their services under each ISD’s provider identifier number.
State officials characterize the C4S program as a three-legged stool – consisting of Medicaid, the ISDs and the Michigan Department of Education (MDE) – all closely coordinating together to support the behavioral health needs of students. Even prior to the reversal of the free care rule, Michigan ISDs worked closely with the state Medicaid agency to provide IEP services for Medicaid-enrolled students. The strong relationship between Medicaid and the ISDs can be credited, in part, to a payment agreement that provides ISDs with 60 percent of federal Medicaid reimbursement for school-based services. To provide schools the support needed to manage the service expansion through C4S, ISDs receive 95 percent of the federal share for services covered under the program and the state Medicaid agency receives the remaining five percent to cover administrative costs.
Challenges and Solutions
Lack of behavioral health providers: In addition to expanding the scope of Medicaid reimbursable health and behavioral health services, the C4S program also expanded the type of providers who can claim reimbursement for delivering services to Medicaid-enrolled students. While funding from the legislature allowed the state to hire new mental health staff, the C4S program still needed additional providers because similar to many states, Michigan was already facing shortages within its mental health workforce.
In response, Michigan’s Medicaid officials employed a creative approach to ensure there were enough providers to support the expansion of school behavioral health services. Recognizing the potential of utilizing other categories of providers, such as physician assistants, nurse practitioners, behavior analysts, and marriage and family therapists, state officials incorporated them and others into the list of allowable providers. Including these additional provider types expanded the behavioral health workforce pool and helped the state address the lack of providers, particularly in rural areas of the state.
Overall complexity of reimbursement process: State Medicaid agency officials indicated that some school districts were initially hesitant to participate in the C4S program because they were concerned about the potential administrative burden that might be involved with implementing the Medicaid reimbursement process. These concerns have been addressed by establishing strong communication channels among the three entities (Medicaid, ISDs, and MDE) to clarify processes and procedures and provide ample opportunities for staff training sessions.
Given the complexity of the reimbursement process, the state Medicaid agency works particularly closely with the ISDs to provide them with answers to specific questions. Training on implementing the reimbursement processes occurs frequently, both at an annual conference and on a regular basis because of the frequency of staff turnover in the schools and consequently the need to train new employees about the procedures and how to account for time spent providing services.
One key aspect of the Medicaid reimbursement model is that the state uses a process that is based on paying for part of the salary of a particular staff position, rather than reimbursing for the actual services themselves. Given that providers do not spend all of their time engaging in reimbursable activities, in order to determine the amount of their salaries that can be reimbursed by Medicaid, state officials must estimate the portion of time they spent on providing medically eligible services to Medicaid-enrolled children. To do this, each month state officials ask for responses to a Random Moment Time Study (RMTS), which is a federally approved method to assess how providers spend their time. The RMTS data is incorporated into an algorithm containing a number of other factors, and this calculation forms the basis of the Medicaid reimbursement model.
State officials reported there are still some challenges associated with helping providers understand how to evaluate their time spent providing services when they respond to requests for RMTS data, due to some providers’ lack of familiarity with the RMTS process as well as the accelerated pace of implementation of the C4S program. However, state officials indicated that they expect these issues can be addressed with additional training.
Provider and general reimbursement issues: One challenge the state encountered during the initial stages of C4S implementation was due to an existing rule within MDE, which stipulated that if a provider’s salary was partially funded by general education dollars that individual was not permitted to work with special education students. State Medicaid officials worked with MDE to eliminate that rule, and this has resulted in the ability to more effectively and efficiently allocate providers’ time and allow them to serve more students.
Another key to the state’s success in increasing Medicaid reimbursement for behavioral health services provided in the schools was to address the reimbursement rate applied to school psychologists. There are four different pools of staff providers serving students — direct services staff, personal care services staff, targeted case management staff, and administrative and outreach staff. Prior to implementation of C4S, the school psychologists were categorized as part of the administrative outreach pool, resulting in a low Medicaid reimbursement rate. State officials were able to work with the Centers for Medicare & Medicaid Services (CMS) to change that designation so they were instead recognized as part of the direct service staff pool, which significantly increased their reimbursement rates.
Michigan state officials also anticipated a potential administrative challenge related to provider reimbursement. If the state used two separate Medicaid state plans to implement the program — one for special education students and another for general education students — this would create reimbursement complications because it would silo providers into serving only one student population group. By instead submitting a SPA for the C4S program that added in coverage of the general education students, this allowed providers to serve both groups of students. The state also worked closely with CMS on the overall reimbursement methodology to maximize the program’s potential for leveraging federal Medicaid funds, which included keeping the students with IEPs separate from the general education students in the state’s calculations because of their differing Medicaid eligibility rates.
Transition to online school services due to COVID-19: Michigan officials had to quickly adjust policies and processes in response to the statewide shift to online learning in the spring of 2020 due to the COVID-19 pandemic. State officials had heard anecdotally about an increased need among students for behavioral health services due to stresses associated with the pandemic, and they anticipate that this demand may continue to grow. Recognizing the need to increase access to behavioral health services for students who may be in crisis, the state waived the requirement that a plan of care must be in place, allowing schools to bill Medicaid up to 30 days without an existing plan of care.
State officials quickly broadened their telehealth policies to include an audio-only provision, and while that will most likely be discontinued when the pandemic ends, they indicated that they plan to sustain many other telehealth provisions post-pandemic.
Also, while telehealth services were implemented fairly rapidly, state officials reported that changing the billing processes was not as easy. School closures caused nearly all RMTS moments to show no reimbursable activity, because providers were not providing medical or behavioral health services during the initial stages of the closure. State officials explained that while this did result in a notable loss in reimbursement, the enhanced Federal Medical Assistance Percentage (FMAP) provided by the Families First Coronavirus Response Act would help cover much of this decrease. Also, CMS allowed the state to use an average of RMTS responses from the last two quarters for their RMTS when schools were closed, because of the significant declines in time spent providing care, and state officials indicated that federal approval to do this helped significantly.
The state is also seeking to ensure equitable access to behavioral health services by focusing on addressing issues for students who lack access to devices that can be used for telehealth services. State officials recently submitted a SPA to federal officials to obtain reimbursement for providing students in need of devices with access to iPads and computers that would be owned and managed by the schools. They indicated that if the proposal is approved, they plan to continue reimbursing for devices beyond the pandemic period.
Overall successes: The C4S program has not only achieved one of its overall goals of increasing students’ access to behavioral health services, it has also helped bring in needed additional funds to the schools. There had already been some psychologists in the schools, but it was not until implementation of C4S that Michigan was able to obtain Medicaid reimbursement for any qualifying services provided. Also, despite needing to navigate the challenges associated with the pandemic, state officials considered it a success that there has been an approximate 6 percent increase in the amount of federal Medicaid reimbursement being directed to schools through the C4S program.
The Future of C4S
State officials said they anticipate that C4S’ initial successes will continue and that the program will likely expand further, as not all ISDs were able to implement the program fully during its initial stages. As school hiring begins to increase post-pandemic and as providers and ISDs become more familiar with navigating the RMTS responses and overall reimbursement process, state officials indicated they expect the program to grow steadily in the coming months.
Notes
The National Academy for State Health Policy (NASHP) would like to thank state officials from Michigan for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
[1] Mental Health webpage on the School-Based Health Alliance webpage, https://www.sbh4all.org/school-health-care/health-and-learning/mental-health/.
[2] Stephen W. Patrick et al, “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey. Pediatrics October 2020, 146(4). https://pediatrics.aappublications.org/content/146/4/e2020016824
[3] Medicaid and CHIP Payment and Access Commission (MACPAC), “Medicaid in Schools.” April 2018. https://www.macpac.gov/wp-content/uploads/2018/04/Medicaid-in-Schools.pdf
[4] Heather Clapp Padgette, Candace Webb, Phyllis Jordan, “How Medicaid and CHIP Can Support Student Success through Schools.” Georgetown University Center for Children and Families, April 2019. https://ccf.georgetown.edu/2019/04/24/how-medicaid-and-chip-can-support-student-success-through-schools/
[5] While the C4S program serves all students, the state can only receive Medicaid reimbursement for services provided to Medicaid-eligible children. Also, the C4S program also expands school nursing services, but this case study focuses on the program’s behavioral health services.
[6] Also, the non-federal share of Medicaid spending for school-based services is provided by schools through certified public expenditures.
Rhode Island’s Accountable Entities Emphasize Children’s Health and Social Needs
/in Policy Rhode Island Blogs, Featured News Home Chronic and Complex Populations, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Housing and Health, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Elinor HigginsIn the midst of the pandemic, many states are continuing to advance their health system transformation efforts. Rhode Island’s Medicaid Accountable Entities (AE) Program, for example, is shifting to a pay-for-performance model for several screening measures. Under this model, there is an additional financial incentive to screen children and their families for health and social needs, which have taken on new importance due to the added stressors of COVID-19.
Rhode Island’s AE program, now entering its fourth year, makes provider organizations (AEs) accountable for health outcomes of their members as well as the total cost of care of their populations. Using contractual levers in the agreements between AEs and managed care organizations (MCOs), the state requires AEs to integrate strategies to address social needs and social determinants of health (SDOH). The strategies must include assessment of social needs, referral to community resources, and utilizing community partnerships and engagement to address the identified needs.
Read NASHP’s 2018 profile of Rhode Island’s Accountable Entities Program here.
The state developed SDOH screening requirements for the AEs. Screening tools must be approved by the Rhode Island Executive Office of Health and Human Services (EOHHS), and they must include information on the following domains: housing insecurity, food insecurity, transportation, interpersonal violence, and utility assistance.
Screening for a child’s needs can offer insights about what kinds of services, referrals, or wrap-around care are needed to ensure healthy development. Because the ongoing pandemic has required children and families to stay home and spend additional time together, a safe and supportive home environment is especially crucial for children’s health and well-being. The SDOH screening domains that are required by EOHHS overlap with adverse childhood experiences (ACEs), such as poverty, food and/or housing insecurity, neglect, and mental illness — all of which contribute to poor health outcomes for children.
Rhode Island’s AE program takes into account the benefit of a two-generation (2Gen) approach to these issues. Under a 2Gen framework, services are provided to both children and the adults in their lives simultaneously to help families live healthy and productive lives. When screening children under age 12, Rhode Island’s SDOH screening measure can be applied to an entire household instead of to only the individual child. This can provide a better understanding of how to target interventions for the whole family going forward.
This year, a key change is happening within the AE program that may increase the number of children and families served by the program. The state is shifting to pay-for-performance (P4P) for the SDOH screening requirement. Beginning in Project Year 4 (PY4), there is a financial incentive for the AEs to increase their SDOH screening rates among their attributed populations. AEs needed time to develop their screening tools and build capacity around screening for SDOH before shifting the AE incentive metric to P4P. Other measures, including documented developmental screening for children younger than age 3, will also transition to P4P in PY4.
Though the SDOH screening requirements are specific to Medicaid AEs in Rhode Island, state officials expect the screening requirements to have a ripple effect. In primary care settings, for example, if a provider is administering the SDOH to AE-attributed patients, officials expect they are likely integrating the screening into their workflows and administering it to all of their patients. This has proven to be the case with other well-child practices. For example, the AE Coastal Medical, has implemented universal screenings across all of its practices to assess and identify needs around depression, anxiety, and SDOH.
Screening is only the first step in improving health-related social needs for children and families. One of the goals of the AE program is to use screening results and the improved understanding of its members’ circumstances to improve their overall health. Rhode Island is leveraging its Quality Report System (QRS), a tool for data collection, to calculate performance on the quality measure. This tool enables providers to drill down to the patient level to identify patients still in need of screening.
An upcoming strategy to help AEs coordinate better with community partners is the procurement of a community referral system that would help connect individuals to necessary resources. Such a referral network could be linked with the QRS in the future, making data collection, analysis, and referral a centralized process. Ultimately, this initiative may drive a broader conversation about how the state collects screening data across both public and private payers, and how this data can be used to improve the health outcomes of Rhode Island residents.
Recent State Actions to Address Declining Children’s Insurance Coverage Rates
/in Policy Florida, Georgia, Iowa, New Jersey, Utah Blogs, Featured News Home CHIP, CHIP, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Healthy Child Development, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care /by Gia GouldSince reaching an all-time low in 2016, the rate of uninsured children has climbed from 4.7 percent in 2016 to 5.7 percent in 2019. In response, several state legislatures are considering bills designed to improve children’s coverage options and promote child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP).
Program and Enrollment Expansions
One of the most notable efforts to expand children’s coverage was included in New Jersey Gov. Phil Murphy’s fiscal year 2022 budget, which establishes the Cover All Kids initiative to provide coverage to all uninsured children. At an estimated cost of $20 million, it is forecasted to cover 88,000 children by expanding Medicaid eligibility thresholds and extending coverage to children currently ineligible due to immigration status.
The Cover All Kids program aligns with initiatives previously proposed by New Jersey advocates and legislators to ensure all children have coverage. The governor’s proposed budget also directs the Department of Human Services to eliminate premiums and the waiting list for children enrolled in CHIP and provides funds for an enhanced outreach campaign to increase Medicaid and CHIP child enrollment.
In Utah, lawmakers considered two children’s coverage bills during this session. In 2019, Utah had the third-highest increase in the rate of uninsured children and the highest rate of uninsured Latinx children in the country. In response to these troubling statistics, the Utah Legislature passed HB262, which creates the Children’s Health Care Coverage program. This program directs the Utah Department of Health, Department of Workforce Services, and the state Board of Education to develop a program to promote health insurance coverage for children when they enroll in school and when they apply for free and reduced lunch.
The Utah law also requires the state to:
- Conduct research on families who are eligible for Medicaid and CHIP to determine their awareness of coverage options;
- Analyze trends in disenrollment to identify barriers for coverage renewal; and
- Administer surveys to gather information about current enrollees’ experiences with the programs.
Findings from this research will be used to redesign the CHIP and children’s Medicaid enrollment websites and inform future outreach partnerships.
Another Utah bill, SB158, designed to address the state’s coverage crisis through the creation of a robust outreach program, focused on enrolling underserved populations, providing application assistance, and launching an advertising campaign to draw attention to coverage opportunities for children. In addition, the bill would have expanded public coverage to children whose family income fell below 200 percent of the federal poverty level (FPL). Despite senate approval, the bill did not pass.
Like Utah, Florida experienced a dramatic increase in childhood uninsured rates since 2016. The Center for Children and Families at Georgetown University’s Health Policy Institute 2020 report found that more than 55,000 Florida children had lost coverage between 2016 and 2019, representing the second-highest coverage drop in the nation during that period. Florida legislators are currently considering HB 201 and SB 1244, both of which would increase the eligibility threshold for their CHIP program from 200 percent of FPL incrementally by 20 percent each year beginning in the 2021-2022 fiscal year, until reaching 300 percent of FPL, which is expected in the 2026-2027 fiscal year.
In Maine, legislators are considering LD 372, a bill to expand access to CHIP. The bill includes provisions to:
- Expand income eligibility from 200 to 300 percent of FPL;
- Eliminate the waiting period for children whose families have lost employer-sponsored coverage;
- Extend coverage eligibility from age 19 to 20; and
- Eliminate premium payments for all enrollees.
Express-lane eligibility:
Last week, the Georgia Legislature passed HB 163, which directs the Department of Community Health to seek federal approval to establish express-lane-eligibility (ELE) for children whose families apply for the Supplemental Nutrition Assistance Program (SNAP). By implementing the ELE option, children will automatically be enrolled or renewed in Medicaid or the state’s CHIP program, PeachCare for Kids, based on the current information provided in their SNAP application. State child health advocates estimate that this could increase child enrollment in Medicaid in the state by 70,000. Currently, five states use SNAP data to determine eligibility for Medicaid and/or CHIP.
CHIP Buy-in Programs:
Legislators in Iowa and West Virginia are considering bills to create CHIP buy-in programs, which allow families with incomes above their state’s CHIP eligibility thresholds to purchase coverage.
Iowa’s SF220 would allow families to purchase CHIP coverage for children and young adults up to age 26 whose household income exceeds the maximum income eligibility threshold of 302 percent of FPL. Iowa’s CHIP-buy in plan differs from traditional CHIP buy-in programs as it would allow families to purchase CHIP coverage for their children as an alternative to qualified health plans on the exchange or plans on the individual market — which unlike CHIP are not tailored to children’s needs.
The CHIP coverage would be sold through the marketplace, allowing families to compare their coverage options, and could be paid for with premium tax credits for eligible enrollees. If passed, the state would need federal approval to implement the plan.
West Virginia’s HB2278 would establish a buy-in program for children’s whose families earn more than 300 percent of FPL and could afford to pay the cost of CHIP coverage in full.
Despite states continuing to grapple with managing the COVID-19 pandemic, many are still seeking to improve coverage for children in Medicaid and CHIP. The National Academy for State Health Policy continues to track states’ efforts to increase enrollment in children’s coverage in Medicaid and CHIP.
States Begin to Incorporate Children into their COVID-19 Vaccine Distribution Plans
/in COVID-19 State Action Center Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, COVID-19, Health Equity, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health, Vaccines /by Olivia RandiTo date, there have been more than 2 million COVID-19 infections in US children and 8,000 pediatric hospitalizations. As states begin vaccinating those age 16 and older, many are drafting plans and applying lessons learned from their existing vaccination initiatives for the day when a vaccine is authorized for younger children.
As the Biden Administration rolls out its comprehensive plan to vaccinate 100 million American adults in the next 100 days and reopen schools in 100 days, states are already taking actions to include children in their vaccine distribution plans and tackling issues, such as:
- Should schools require students to get the COVID-19 vaccine, similar to other immunization requirements?
- How should they prioritize children with medical conditions or living in congregate settings that put them at higher risk of infection?
Background
Children are at lower risk of illness from COVID-19 than adults, yet this population can still develop symptoms and spread the virus to others. Though children have experienced fewer severe physical illness than adults, the pandemic has significantly impacted their emotional and social development. Children and their families have been stressed by social distancing, disruptions in schooling, unemployment, and loss of family members due to COVID-19.
Last October, states submitted COVID-19 vaccine distribution plans to the Centers for Disease Control and Prevention (CDC) that outlined their approaches, including how they will collaborate with stakeholders, enroll providers, and track vaccinations. The federal Advisory Committee on Immunization Practices (ACIP) has recommended vaccinations first for health care personnel and long-term care facility residents, people 65 and older, essential workers, and those with high-risk medial conditions. States are using these recommendations to guide their approaches to prioritizing populations for vaccine distribution.
ACIP is currently discussing vaccine trials in pediatric populations and has indicated it may update its recommendations once a vaccine is authorized for children under age 16. Meanwhile, several states have already identified a distribution phase for children in their current plans.
Youth age 12 and older have just begun enrolling in vaccine trials. If the vaccine is authorized for this age group, it will next be tested in a younger pediatric population. While there have been barriers to clinical trials for the vaccine in this population and the timeline is unclear, it will be months before any children under age 16 are eligible for vaccination. As states grapple with challenges in distributing the vaccine to currently eligible populations, they may be able to leverage the lessons they are now learning to improve distribution for younger children in the future.
Additionally, there are already systems in place to deliver vaccines to children, and many states plan to use the Vaccines for Children (VFC) infrastructure for enrolling and verifying providers, distributing, and tracking COVID-19 vaccine administration for all populations, including adults. States may find that these established protocols will facilitate vaccinating children.
States differ in how they have – or have not yet – included children in their vaccine distribution plans while the vaccine undergoes pediatric clinical trials. State approaches include:
- Incorporating child health agency representatives in COVID-19 vaccination planning teams;
- Designating roles for child health programs and providers to facilitate distribution; and
- Prioritizing children or subpopulations of children for when the vaccine is authorized.
Several states have indicated their pediatric vaccination plans may be updated once the vaccine is authorized for children. (See the table for a list of states that have included pediatric-specific approaches in their vaccine distribution plans.)
Including Child Health Stakeholders in Vaccination Planning
States have developed organizational structures that include internal and external agency representation to facilitate COVID-19 vaccination planning. At least 31 states have included child health stakeholders on their vaccine planning teams and advisory councils. These stakeholders include state chapters of the American Academy of Pediatrics (AAP) and other provider groups, children’s hospitals, other pediatric providers, state education agencies, local school districts, and others. Including these representatives in vaccine distribution planning early offers an important perspective for distributing the vaccine when it is authorized for children.
- Washington, DC’s vaccine planning team includes representatives from the District’s chapter of the American Academy of Pediatrics, pediatric providers, public schools, Families USA, and March of Dimes.
- Ohio’s vaccine planning team includes representatives from Ohio Children’s Hospital Association, Ohio Department of Education, and select local school districts.
Designating Roles for Child Health Programs and Providers
Beyond their vaccine planning teams, states have identified and partnered with child health programs and providers to support implementation of their distribution plans. These partners include pediatric practices, local school districts, and state public health agencies, including Title V Maternal and Child Health programs. Forming partnerships with these entities early in the planning process can facilitate rapid vaccine deployment once it is authorized. The specific roles designated to these partners include promoting the vaccine, facilitating communication with children and their families, identifying eligible children, and administering the vaccine.
- Connecticut has identified vaccine administration locations that will specifically serve children. These include school-based health centers and pediatric medical practices.
- North Carolina plans to partner with schools to help identify children for vaccination once it is authorized. The state is also engaged with the state’s AAP and the Pediatric Society to support education and communication about the vaccine.
Prioritizing Children Pending Authorization
Six states (GA, HI, ME, NC, OH, and RI), to date, have identified children as a priority population within Phase 3 of their vaccine distribution plans. During this phase, states anticipate having adequate supply of the vaccine to meet demand. At this point, it is expected that Phase 1 and 2 populations will largely have been vaccinated. Several states have also noted that they will update their vaccine distribution plans to include children when the vaccine is authorized for those under age 16, pending ACIP recommendations. States have also prioritized sub-populations of children, including those in congregate settings and those at higher risk of illness due to COVID-19.
Children and youth in congregate settings:
While children and youth are at a lower risk of illness from COVID-19, those residing in a congregate setting (e.g., residential treatment facilities) are at an increased risk of exposure and transmission, prompting some states to prioritize vaccination of children in youth-specific congregate settings in their distribution plans. Additionally, children and youth residing in congregate settings often have special needs and may have underlying conditions that increase their risk of symptoms due to COVID-19 in addition to their increased risk of exposure. Several states have included children in congregate settings in Phase 1 of their distribution plans. However, if the vaccine is not authorized for those under age 16 during Phase 1, these children would receive the vaccine during a later phase.
- Louisiana’s plan prioritizes residents of psychiatric residential treatment facilities and therapeutic group home facilities, which typically serve youth under age 21. Eligible youth in these facilities are in Phase 1B of the state’s vaccine distribution plan.
- New Mexico identifies residents at county juvenile justice centers and other congregate settings, including residential treatment centers, to receive a vaccine in the later part of Phase 1. The state also works with state agencies to identify critical populations, including youth in shelters, as part of its COVID-19 response.
States with Child-Related Provisions in their COVID-19 Vaccine Distribution Plans as of Jan. 6, 2021
| Child-related component* | States |
| Child health agencies included in vaccination planning teams | AL, AZ, AK, CO, DC, FL, GA, HI, ID, KS, LA, ME, MD, MA, MI, MT, NH, NV, NJ, NM, NY, NC, OH, OR, PA, RI, SC, UT, VA, WA, WY |
| Designated roles for child health programs and providers | CT, HI, LA, ME, NE, NJ, NC, OR, VT, WA |
| Prioritizes children for Phase 3** | GA, HI, ME, NC, OH, RI |
| Prioritizes children in congregate settings** | FL, LA, NM, OK, PA |
| Prioritizes children at higher COVID-19 risk** | HI, KY, ME, NY, OK |
| Specifies that the plan may be updated to include or reprioritize children** | CO, DC, IA, NV, NC |
| * The states listed here have included these provisions in their vaccine distribution plan as of Jan. 6, 2020. Other states may have taken or plan to take these actions, but they are not specified in their plans.
** Pending authorization of the vaccine for children and Advisory Committee on Immunization Practices (ACIP) recommendations. |
|
Children at higher risk of illness due to COVID-19: While the distribution phase differs, most states have categorized people with chronic conditions that increase their risk for illness due to COVID-19 as a priority group for vaccine receipt. Because most states do not specify the age range for this prioritized group in their distribution plans, some of these states may implicitly plan to include children, including children and youth with special health care needs (CYSHCN) who are at increased risk of COVID-19 illness, within this group when the vaccine is authorized for pediatric populations. However, five states (HI, KY, ME, NY, and OK) have specifically included children at higher risk as a prioritized population.
- Oklahoma has prioritized students including those in K-12 schools, childcare facilities, and early childhood facilities for Phase 3 of their vaccination distribution. Within their distribution plans, they specify that students at higher risk due to comorbid conditions will be prioritized among all students.
- Maine’s distribution plan specifies that “people of all ages” with conditions that put them at higher risk will be prioritized for earlier phases of vaccination. Anyone with a condition that puts them at significantly higher risk will be prioritized for Phase 1b, and those with conditions that put them at moderately high risk will be prioritized for Phase 2.
Key Considerations
As the vaccine is tested for safety in the pediatric population, states are considering how they will further incorporate children into their distribution plans if it is authorized.
- Including child health stakeholders in planning for the vaccine for children. Many states have leveraged the existing VFC infrastructure and partnered with child health agencies to support planning and implementation for distribution of the currently available vaccine. This important perspective will be increasingly critical if the vaccine is authorized for use in children. States can consider collaborating with additional stakeholders that represent the broad range of child health services to effectively support vaccine administration for the pediatric population.
- Leveraging lessons learned from distribution of the adult vaccine. States have faced various challenges in distributing the vaccine to those who are currently eligible. Given that children under age 16 will not be eligible for the vaccine for at least several months, states may be able to draw from their experiences to improve their strategies for distributing the vaccine to children while also considering the challenges and opportunities that are unique to the pediatric population.
- Prioritizing caregivers of children with underlying conditions. Many CYSHCN who may have underlying conditions that increase their susceptibility to COVID-19 symptoms are cared for by family members. To reduce the risk for CYSHCN, states can prioritize vaccinating these family members by classifying them as health care workers.
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- Prioritizing sub-populations of children. Children who are at higher risk of COVID-19 due to underlying medical conditions and/or those in congregate facilities are important populations for states to consider for prioritization. Additionally, states can consider how to distribute the vaccine to minimize learning losses due to school closures. CYSHCN may face unique challenges in accessing virtual learning compared to other children, whether or not they are at greater risk of COVID-19 illness. This is particularly true for children of color, those with high socioeconomic needs, and those with limited access to technology. Prioritizing children with greater virtual learning challenges could more equitably facilitate a safe return to in-person learning.
- Determining whether the vaccine will be a school requirement. Several state vaccine distribution plans include language about their state statutes that currently require certain vaccines for children to enter schools. While these plans do not specify that the COVID-19 vaccine is a school requirement, this will be an important consideration for states if the vaccine is authorized for use in pediatric populations.
- Distributing the vaccine across pediatric age groups. Vaccination authorization in children will likely be authorized in stages, with current trials for those ages 12 and older, and subsequent trials for younger age groups. This may impact states’ decisions governing how they prioritize vaccine distribution, when and which schools reopen for in-person instruction, and who, if anyone, is required to have received the vaccine to attend school in person.
The National Academy for State Health Policy will continue to monitor states’ COVID-19 vaccine distribution plans, and how states’ plans change once the vaccine is authorized for children under age 16.
Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials co-operative agreement. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the US government.
Six States Join NASHP and AcademyHealth’s Community of Practice to Boost Immunization Rates in Medicaid-Enrolled Pregnant Women and Children
/in Policy Louisiana, Michigan, Washington, Wisconsin, Wyoming Blogs, Featured News Home Chronic Disease Prevention and Management, Health Equity, Immunization, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper, Jill Rosenthal and Ariella LevisohnThe National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.
Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.
Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.
Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.
State Strategies to Support the Health Needs of Children with Special Needs in Schools during COVID-19
/in Policy Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, COVID-19, Health Equity, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Eskedar GirmashChildren and youth with special health care needs (CYSHCN) and their families face unique hardships in accessing school-based health services during COVID-19, especially children of color, those experiencing poverty, and those living in rural areas who have limited access to technology and acute socioeconomic needs.
States are developing unique strategies to support the health needs of CYSHCN who lack access to their usual school-based physical, developmental, and mental health supports.
These approaches include:
- Upholding requirements mandated by the Individuals with Disabilities Education Act (IDEA) and in particular, Individualized Education Plans (IEP);
- Holding or prioritizing in-person learning for specific populations of children (e.g., CYSHCN, children experiencing homelessness);
- Expanding Medicaid coverage of telehealth in schools; and
- Expanding Medicaid coverage of home health services.
How COVID-19 Impacts CYSHCN
CYSHCN require health care services and supports beyond what children normally require and account for about 20 percent (14.6 million) of US children and youth. Rates are higher across racial and ethnic demographics, with about 25 percent of non-Latinx Black children and youth reporting special health care needs, for example. This inequity is driven by a combination of systemic issues, including factors such as lower rates of access to robust medical homes and lower quality of received care among Black and Latinx CYSHCN.
Recent data from the Centers for Disease Control and Prevention (CDC) shows that children who self-identified as Hispanic, non-Hispanic Black, and Native American/Alaska Native with underlying medical conditions make up nearly 80 percent of children who died from COVID-19. These racial and ethnic inequities are a result of a range of socioeconomic issues including: systemic racism; lack of access to healthcare; education, income, and wealth gaps; and crowded housing conditions. Inequities among CYSHCN have been heightened by the loss of school-based services that provide physical, behavioral, and developmental services and supports.
A May 2020 survey conducted by ParentsTogether found that just one in five parents reported that their children received all the school support services required by their IEP as schools moved to virtual instruction. As school opening policies (in-person, virtual, hybrid) are changing on a weekly basis, it is important for states to closely monitor and improve the accessibility of school-based health services for CYSHCN both in-person and virtual settings.
The US Department of Education released guidance early on in the pandemic requiring local education agencies (LEAs) to provide students with disabilities access to the same educational opportunities provided to the general student population, including the provision of free appropriate public education (FAPE) during the COVID-19 outbreak. The guidance requires schools to uphold the services in a student’s IEP – a tailored education plan designed to meet the unique needs of children with special needs – and requirements under IDEA during any school changes, as a result of the pandemic.
To support districts in their transition to virtual learning during COVID-19, the Georgia Department of Education was awarded $6 million in federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and IDEA funding. The Georgia State Board of Education allocated $3 million to supplement the state’s special education program, including the delivery of IEP plans. Pennsylvania is taking a similar approach, allocating $20 million from the Governor’s Emergency Education Relief Fund and the state’s federal IDEA funding to bolster remote services and supports for students with complex needs and provide services to students with disabilities who experienced a loss in skills or a lack of progress due to school closures.
State Strategies
States have prioritized children with special needs for in-person learning due to their unique needs for access to services and supports, and the current challenges they face in accessing in-person learning. In late August, the California Department of Public Health issued rules to allow for opening of schools to small cohorts of students with “acute needs.” The guidance encourages LEAs to prioritize students with disabilities who receive specialized services, such as occupational therapy, speech and language services, and other medical, behavioral, and educational support services. These cohorts are limited to 14 students and two supervising adults.
Oregon is taking a similar approach by allowing schools to bring a limited number of students (up to 10 per cohort) for up to two hours of in-person instruction daily. Students who receive special education services, are learning English, or lack reliable internet access, are prioritized for in-person learning. It is important for states that have already transitioned students back to in-person instruction to design and implement policies to protect the health of CYSHCN and other vulnerable students. A recent National Academy for State Health Policy (NASHP) blog, State Strategies to Safely Transition Children with Special Health Care Needs Back to School, highlighted additional state strategies to safely transition CYSHCN back to physical school settings.
States are also using telehealth and home health services to increase accessibility to care for CYSHCN that previously received these services in a school-based environment. Since the onset of the pandemic, 31 states have released guidance allowing Medicaid reimbursement of school-based telehealth services and nine are allowing reimbursement of school telehealth services for the first time.
Pennsylvania, South Dakota, and Texas are newly allowing Medicaid reimbursement for school-based audiology, counseling, and occupational, physical, and speech therapy telehealth services. Other states, such as Ohio and Wisconsin, are working on making their telehealth-in-school Medicaid policies permanent post-COVID-19. Additionally, most states are allowing telehealth services to be delivered via audio-only format and with widely available tools, such as Zoom and FaceTime, to make services more accessible.
States are also updating their Medicaid waiver rules to meet the health and educational needs of CYSHCN during remote learning sessions. The North Carolina Department of Health and Human Services recently worked with the Centers for Medicare & Medicaid Services (CMS) to allow families to use Medicaid waivers for home health services delivered at the same time that students are engaged in virtual learning. Families were previously prohibited from doing so because of restrictions on the use of federal funds from different programs (health and educational), as both home health and virtual school services rely on federal funding. North Carolina’s new Appendix K Waiver increases in-person physical health and therapeutic supports for CYSHCN who lost access to these services due to remote learning.
As states consider new policies to better support the health needs of CYSHCN in virtual and in-person educational settings, it is important to consider:
- What specific policies can be developed to support the unique needs of Hispanic, non-Hispanic Black, and Native American/Alaska Native CYSHCN who are disproportionately affected by COVID-19 and school closures?
- Can policies such as expanding Medicaid coverage of telehealth in schools and increasing funding for special education services be leveraged beyond the COVID-19 public health emergency to strengthen care for CYSHCN?
- What role will federal funding play in alleviating state budget pressures as they navigate COVID-19-related shortfalls?
- Can states continue to finance Medicaid-reimbursed home health services in supporting CYSHCN during remote instruction?
NASHP will continue to monitor school-based health policies during the COVID-19 pandemic and the implications for CYSHCN and their families.
State Immunization Services and Policies Resource Page
/in Policy Toolkits Chronic Disease Prevention and Management, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health Immunization /by Rebecca CooperInfographic: Policy Levers to Address Health Equity by Reducing Lead Exposure
/in Policy Featured News Home CHIP, Chronic Disease Prevention and Management, Health Equity, Housing and Health, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Rebecca Cooper and Elinor HigginsThis infographic highlights how lead exposure and poisoning is a health equity issue, and the role that state Medicaid agencies and other systems play in reducing exposure to improve health outcomes. Additional resources are listed below the infographic.
Additional Resources:
- Associations of Maternal & Child Health Programs: Lead poisoning prevention webpage.
This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UJ9MC31105 – Maternal and Child Environmental Health Collaborative Improvement and Innovation Network (CoIIN) for $849.999. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government. NASHP thanks the Maternal and Child Health Collaborative Improvement and Innovation Network (MCEH COIIN) leadership partners for their review of the infographic.
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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. 























































































































































