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States Re-think Contact Tracing and Case Investigation Strategies as COVID-19 Cases Rise
Contact tracing is an essential strategy for curbing the spread of COVID-19. When implemented quickly, isolation of people diagnosed with COVID-19 and identification and quarantine of close contacts can effectively interrupt disease transmission and reduce spread. Faced with rapidly climbing caseloads, testing delays, and increases in community spread, states and localities have had to prioritize high-risk cases, utilize technology in new ways, and implement creative strategies to conduct case investigations, trace contacts of infected individuals, and perform follow-up.
Contact tracing works best when quick follow-up is possible, sufficient testing resources are available, and when social isolation and quarantine are possible. Due to recent case spikes, contact tracers in some states are unable to call COVID-19-positive individuals fast enough. Additionally, with some regions reaching an accelerating state of community spread, it is more difficult to determine exactly where individuals were exposed to COVID-19. In North Dakota, these issues led to a major shift in contact tracing protocols. Since October, the state has asked infected individuals to notify their close contacts and direct them to resources on the Department of Health’s website.
Recently, other states have followed suit:
- The Maine Center for Disease Control and Prevention will make only one contact with an infected individual (instead of checking in with them periodically) to provide guidance. It will also enroll people in the program based on when their last contact with someone with COVID-19 was. That way, they will enroll people who have the highest number of days left in their 10-day quarantine period so Maine CDC can work with them as early as possible to limit exposure to others in the community. The state is also limiting its contact tracing to high-risk individuals, including those age 65 and older, health care workers, children, individuals of color, school workers, and congregate living facility residents.
- As of mid-November, Nebraska had a backlog of 2,600 people who had tested positive for COVID-19 but had not been contacted by a contact tracer. To address the backlog, the Department of Health and Human Services reduced the number of call attempts from five to two, reduced the number of interview questions, and asked individuals to call their own contacts to let them know they tested positive.
- New Hampshire began focusing on contact tracing for high-risk populations including health care workers, communities of color, and people living in group living spaces. The state is also asking health care providers to educate COVID-19-positive patients about isolation and quarantine procedures.
- Oregon has shifted tracking priorities as its case counts rise drastically to protect the state’s most vulnerable residents in long-term care facilities, jails, foster homes, etc. Contact tracers are still advised to perform the first two steps of tracing: interviewing new COVID-19 cases and finding their contacts and notifying them to get tested and quarantine, but they will no longer do ongoing monitoring of these groups.
- Pennsylvania is prioritizing case investigations of its most vulnerable residents, such as those in nursing homes, or cases that could lead to greater community spread.
- In Wisconsin and Wyoming, only individuals who have tested positive for COVID-19 will hear from contact tracers. Individuals are instructed to reach out to their own close contacts.
Since spring, states have shifted their approaches to contact tracing to reflect current needs. The examples above show that states are currently focused on maximizing contact tracing effectiveness by focusing on known or presumed positive cases and working to protect those at increased risk through a more targeted approach to contact tracing outreach.
Additionally, several of these states have been financing their contact tracing efforts with federal funds and there is some uncertainty about whether these funds will be renewed. With the year drawing to a close, there are competing demands for these resources as states prepare for vaccine distribution and education, and funding has likely played into decisions to cut back instead of hiring new contact tracers.
In response to state actions like the ones above, the US Centers for Disease Control and Prevention (CDC) released new guidance on Dec. 3, 2020, about how to prioritize contact tracing and case investigation in states and jurisdictions where cases are on the rise. The new directions were guided by several principles:
- Maximizing effectiveness;
- Protecting household contacts;
- Preventing outbreaks and clusters; and
- Protecting people at increased risk.
Source: Virginia has adopted these guidelines and will join the list of states that are using contact tracing prioritization as a way to address surging cases.
States can use other strategies in their contact tracing work to maximize value, including technology. As of Dec. 1, 17 states were using the Google and Apple exposure notification technology that alerts individuals when they have been in close contact with someone who has tested positive for COVID-19. There is an increasing focus on these phone applications working across state lines as the technology becomes more standardized. In other states, technology is being used to connect people with quarantine resources—a strategy that can make contact tracing more effective.
For example, in Connecticut, a statewide software system called ContaCT monitors test results and positive cases. The ContaCT platform will identify and refer people who need support at initiation and throughout self-isolation or self-quarantine. Case workers will support people in self-isolation or self-quarantine by connecting them with state, local, and regional resources as necessary, such as food and housing.
Other states are using a range of strategies to improve the efficiency or effectiveness of their contact tracing programs in the face of rising caseloads and hospitalization rates:
- The Ohio Department of Health is updating its systems to allow local health departments to enter information about an infected person’s contacts prior to their positive test to get a better idea of where the virus is likely to spread.
- Since August, Washington, DC contact tracing efforts have included home visits for high-risk individuals who did not complete contact tracing interviews or could not be reached by contact tracers.
- North Dakota, South Dakota, and Vermont have recently revived their partnerships with the National Guard to help with elements of contact tracing and case investigation.
- In New Mexico, businesses that have had a confirmed COVID-19 case or exposure among staff can avoid a 14 day Rapid Response Closure by signing a surveillance testing and contact tracing In the document the employers must agree to conduct testing among their staff and select a COVID-19 coordinator responsible for working with the NM Department of Health on contact tracing efforts in the workplace.
- South Dakota is incorporating texting and email into their initial outreach strategy, replacing phone calls in some cases. This approach can be more automated and will allow individuals to input their own information to a secure online portal even if they are unable or unwilling to answer the phone.
Contact tracing is just one piece of the puzzle when it comes to mitigating the spread of COVID-19. Increased public education about the importance of mask wearing and social distancing, as well as increased testing and resources for effective quarantine will also be critical for curbing the spread. As COVID-19 case numbers rise and fluctuate this winter, states are expected to continue to adjust their contact tracing and case investigation strategies to meet their needs and utilize available resources. The National Academy for State Health Policy, in partnership with Mathematica, will continue to track and analyze state efforts.
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.
With Federal Guidance Evolving and Vaccine Supplies Uncertain, States’ COVID-19 Vaccine Distribution Plans Remain Works in Progress
This map and chart show how each state prioritized their populations in their vaccine distribution plans, submitted to the Centers for Disease Control and Prevention in October 2020.
As COVID-19 infections, hospitalizations and deaths soar and federal guidance evolves, states are finetuning their vaccine distribution plans as the US Food and Drug Administration (FDA) appears poised to approve a vaccine later this week. The timely, safe, and equitable distribution of the vaccines falls squarely on states and their providers, who are already stretched thin in dealing with the pandemic and need billions of federal funds to distribute the vaccines successfully in the months ahead.
Fueled by the challenges that confronted the distribution of testing supplies and personal protective equipment (PPE) earlier this year, and the knowledge that vaccine demand vastly exceeds current supply, states are developing distribution plans that will target high priority populations without clearly scheduled deliveries.
Supported by $200 million from the Coronavirus Aid, Relief, and Economic Security (CARES) Act for vaccination preparedness, state plans that addressed ordering, storage, handling, and distribution priorities were submitted to the Centers for Disease Control and Prevention (CDC) in October. Each state’s plan takes federal recommendations into consideration but are unique and reflect their workforce and population priorities.
CDC’s Advisory Committee for Immunization Practices (ACIP), which states historically rely on for vaccine guidance, will hold an emergency meeting to vote on their prioritization and vaccine recommendations after FDA votes to approve the vaccine later this week. However, if distribution begins 24 hours after FDA approval as planned, many states may receive the vaccine before ACIP issues recommendations.
How State Distribution Plans Vary
A National Academy for State Health Policy (NASHP) analysis finds that as of October, no two states have prioritized their populations in exactly the same way. While most state allocation plans are informed by federal guidance (CDC and/or NASEM), many have enhanced their plans based on recommendations from their own advisory boards or equity committees.
It is expected that as more information on vaccine doses and recommendations is released by federal panels, states may increase the specificity of their prioritization criteria.
Key differences between state distribution plans include:
- Number of phases: States vary in the number of phases they plan for allocation, from two phases (Maryland, Nebraska) to five phases (Montana, New York). Most states have three or four phases, with some of them subcategorized further into A, B, and C.
- Delineation of phases: Several states have not yet delineated which populations fall within each phase or have only identified Phase 1 target audiences. These states are either waiting for more federal guidance or are working with state task forces and committees to determine their phased approach.
- Estimates of numbers within each priority group: Roughly 40 percent of state plans report how many individuals are in each priority population. Others are still determining how many people they expect to vaccinate during each phase. These details could influence distribution plans as states would need adequate supply of vaccines for all individuals within a particular phase. States plan to use various GIS mapping techniques and other software to identify where priority populations live within the state.
- Targeting specific high-risk populations: Some states include racial and ethnic minority groups, tribal populations, and rural populations within a specific phase. Others plan to recruit vaccine providers serving rural or underserved areas early on, but do not specifically list these groups as a target population within any particular phase.
- Nuance of priority populations: States vary significantly in how they delineate target populations for each phase. For example, some states group all essential workers, or all inhabitants of congregate care facilities, in one phase. Others target distribution for specific populations with more nuance, like prioritizing people in congregate settings who are 65 or older over younger adults living in congregate facilities (like homeless shelters or prisons). This will place more responsibility on facilities and health care systems to decide on a nuanced distribution strategy during the initial distribution period.
Across the board, Phase 1 prioritizes vaccinating health care workers (HCWs). While all states prioritize HCW, some specifically identify who qualifies as an HCW (e.g., clinical staff vs. support staff who work in a medical facility, including janitorial and administrative staff). ACIP’s vote on Dec. 1, 2020, recommended states include residents of long-term care facilities (LTCF), such as skilled nursing facilities, nursing homes, and assisted living facilities, in Phase 1A of the distribution along with the previously recommended HCW. States who do not already list residents of LTCF in their initial phase will need to decide if they will incorporate ACIP’s recommendation into their distribution strategy and change their plans.
Not all states reported on all populations. Of the states that provided detailed information about how distribution would be prioritized within phases, NASHP found:
- Forty-two states included HCW in Phase 1A of distribution.
- Nineteen states included residents of LTCF in Phase 1A, and 21 states included LTCF residents in Phase 1B, six states designated that population in Phase 2 and one state designated for Phase 3.
- Six states (Delaware, Michigan, Mississippi, New Mexico, Pennsylvania, and Utah) further sub-prioritized distribution to HCW, by specifying paid and unpaid employees who are at highest risk of coming into contact with someone with COVID-19 to receive the vaccine first in Phase 1A, followed by other essential HCWs critical to maintaining the health care system, including administrative and janitorial staff, in Phase 1B.
- Ten states do not yet specify sub-prioritization of Phase 1 in their plans.
What is the initial vaccine distribution strategy?
Of those states that have issued guidance on how to sub-prioritize HCW, they have done so in three ways:
- Based their distribution on population. Allocation within the state will be proportional to the number of health care workers in the area.
- Designed distribution based on COVID-19 prevalence. Hospitals and facilities that have more cases of COVID-19 will get more doses of vaccine. In Utah, priority distribution will go to the top four hospitals treating the most COVID-19 patients, and in New York, HCW in areas with high COVID-19 prevalence are anticipated to receive the vaccine before HCW in areas with lower case rates.
- Use job responsibility. Certain HCWs will be prioritized over others. In Pennsylvania, the first doses will go to providers working in emergency departments, on inpatient floors, and in intensive care units.
In Kentucky, according to Gov. Andy Beshear, the first doses of the vaccines will be shipped to 11 hospitals. Kentucky is expecting to receive 38,025 doses of the Pfizer vaccine, and 76,700 doses of the Moderna vaccine. The Pfizer vaccine doses will be used to vaccinate 26,000 of the state’s nursing home residents and staff, and 12,000 more of the Pfizer doses will go to the frontline HCWs at greatest risk of exposure. California Gov. Gavin Newsom announced the state expects to receive 327,000 initial doses in mid-December, but the state is home to 2.4 million HCWs, with 1 million working in acute care hospitals and around 150,000 working in nursing homes. Tennessee anticipates receiving 56,550 doses of the Pfizer vaccine in the first immediate phase and the state plans to reserve one tray of 975 doses in case any vaccine spoils when shipped to facilities. Tennessee also plans to set aside 5 percent of its first shipment of the Moderna vaccine in case of spoilage (about 5,000 doses), with the rest of the doses going to each county health department.
Additionally, states will have to decide whether to save some of their initial doses for a second round of immunization for the first priority groups, or use their entire supply of vaccine and hope they are able to receive a second shipment in time to give HCWs their second dose within the required timeframe. Current guidance, as reflected in some state plans like Washington’s and Tennessee’s, suggest that the federal government plans to hold back doses and send a second shipment at a later date that is intended for second doses for these first individuals. The states do not know when to expect the next shipment of doses, or how many they will get in the follow up shipments.
How are states prioritizing other key populations?
State plans vary in specificity of phases for vaccinating other specific critical populations and are dynamic documents that are constantly updated. For states that did delineate, NASHP noted these trends:
- Teachers are a high-priority population. Twenty-two states plan to vaccinate teachers at some point during their Phase 1 distribution and 12 states list teachers in Phase 2.
- Incarcerated populations and correctional officers are usually in Phase 1 or 2. Nine states plan to vaccinate incarcerated people at some point in phase 1, 27 states plan to vaccine incarcerated people in Phase 2, and two states plan to vaccinate them in Phase 3. In contrast, 10 states plan to vaccinate correctional officers in Phase 1, and 13 states have plans to do so in Phase 2.
- Most states include individuals living in homeless shelters in phase 3. Eight states plan to vaccinate individuals living in homeless shelters at some point in Phase 1, 22 states plan to do so in Phase 2, and three states plan to do so in Phase 3.
What support do states need for successful distribution?
States have been planning for vaccine distribution for months, but acknowledge that their plans are working documents, and will need to be refined as more federal guidance and more information about the number of doses states can expect to receive become available. Key considerations include:
- ACIP’s upcoming vote following emergency use approval by the FDA regarding who should receive the vaccines and in what order, and then continued guidance as the situation evolves. As more data from the vaccines’ Phase 3 clinical trials become available, more changes might be made in distribution recommendations.
- Federal leadership and potential new funding to strengthen state and local distribution infrastructure as CARES Act funding expires on Dec. 31, 2020. States need to procure more personal protective equipment , set up socially distanced mass-vaccination sites, provide public information to encourage immunization and complete the logistics of delivering and tracking to priority populations.
- Other vaccines in the pipeline which may affect the timeline of the phases for each state, and equitable distribution of the vaccine.
While the vaccine will ultimately be available to everyone, states must make important policy decisions to ensure timely, ethical, and equitable distribution of the vaccine during initial phases when supply is limited
As states continue determining their priority populations and phased approaches, they anxiously await a stimulus package from Congress that includes much needed support for vaccine distribution. As the vaccine becomes available and states begin to roll out administration, NASHP will continue to track all aspects of the COVID-19 vaccine distribution process and engage with states to address challenges.
Support for this work was provided by Centers for Disease Control and Prevention.
Harm Reduction in the COVID-19 Era: States Respond with Innovations
Despite COVID-19 workarounds, such as telehealth and virtual recovery programs enabled by flexible federal guidelines, more than 40 states have reported increases in drug overdoses during the pandemic, underscoring the importance of keeping state harm reduction programs as accessible as possible.
As COVID-19 upends the nation’s health care systems, treatment for substance use disorder (SUD) has shifted to telehealth environments and recovery programs have gone virtual as state and federal policymakers adjust regulations and guidance to maintain access to services. But the unique risks facing people with SUD during this time of isolation and mandatory social distancing are also becoming more clear.
State-authorized harm reduction programs that provide syringe exchange services, testing for infectious diseases and referral to treatment, and connections to treatment for opioid use disorder and other SUDs provide a critical intervention. Despite the challenges of implementing COVID-19 protocols for what have traditionally been in-person services, states have developed flexibilities and innovative approaches to ensuring that these programs continue to provide critical, ongoing support to people with SUD until they are ready for treatment.
State guidance for harm reduction providers in response to COVID-19:
The guidance that state officials and agencies have developed recognize the unique challenges that face harm reduction providers during the COVID-19 pandemic. Many states acknowledge harm reduction as an essential service and some have temporarily loosened program restrictions to ensure the continuity of services during the pandemic.
- The Oregon Health Authority (OHA) authorized its Syringe Service Programs (SSP) to provide curbside services and phone orders for syringes, naloxone, and other supplies. OHA also suggested operational shifts in staffing, distancing protocols, and volunteer management to mitigate COVID-19 transmission among staff, volunteers, and clients. OHA included messaging in support of people who use drugs (PWUD) in order to maintain their safety during the pandemic. The messaging emphasized the increased respiratory risks associated with drug use and COVID-19 and provided guidance on how to reduce the risk of COVID-19 infection as well as the risk of overdose during the pandemic.
- In Maine, Gov. Janet Mills issued an Executive Order on March 30, 2020, suspending an existing one-to-one syringe exchange rule, thereby increasing the number of syringes individuals can take home at once. The order also allows flexibility in mail delivery services, needle exchange site locations and operational hours and provided on-site social distancing protocols.
- The Missouri Department of Mental Health issued comprehensive COVID-19 guidance in mid-March, which featured published resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Harm Reduction Coalition, and the National Health Care for the Homeless Council (NHCHC), as well as best practices from other states and programs. Missouri’s guidance includes operational directives for treatment and harm reduction providers, as well as practical harm reduction guidance for PWUD, particularly individuals who use drugs alone.
Adaptations in harm reduction services:
Harm reduction programs are making policy shifts to develop practices that respond to the specific needs of their communities. As states and municipalities have responded to the COVID-19 pandemic at varying degrees of restrictiveness, harm reduction programs have also tailored their programs to respond to the pandemic.
- Operational changes. Programs in Washington and other states have shifted services outdoors. They now provide curbside or mobile services and have closed their fixed sites entirely and instead rely on delivery services. Many Washington State SSP programs have limited hours and scope of services. In New York, SSPs have been operating with skeletal staff and reduced resources. In response to the new limitations on in-person service, 22 of 23 of New York’s SSPs now rely on some form of peer-delivered syringe services.
- Shifts in testing priorities. In addition to continuing to provide harm reduction services, some SSPs in Washington now provide COVID-19 screening and testing at their program sites. West Virginia’s harm reduction programs have reduced the amount of non-COVID-19 infectious disease testing they’re conducting and the amount of hepatitis A and B immunizations they administer, in order to focus on COVID-19 and the immediate needs of individuals with SUD.
- Emphasizing naloxone distribution. As overdose rates continue to rise during the pandemic, states are increasing access to the overdose-reversal drug naloxone. Pennsylvania’s Secretary of Health signed an updated standing order that allows community organizations to distribute naloxone through mail. Ohio’s Department of Mental Health and Addiction Services has provided official guidance to all community programs through its statewide Project DAWN overdose reversal initiative to maintain minimal contact with individuals who need services while maximizing naloxone distribution as a strategy to mitigate overdoses. Additionally, the US Department of Health and Human Services has published guidance for first responders to safely administer naloxone during the pandemic.
Looking Ahead
As states begin to consider the impact of COVID-19 on their budgets, programming, and future planning, maintaining harm reduction programs may become more challenging. Harm reduction programs are often supported by multiple funding streams, and program administrators and policymakers may consider leveraging federal grants and other non-state funds to maintain these services. In addition to ensuring access to infectious disease prevention and life-saving treatment and recovery services, harm reduction programs offer a mechanism to maintain engagement with people who have SUD and reduce their risk of overdose, which results from isolation.
This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for foundation purposes notwithstanding any copyright notation hereon.
Webinar: Avoiding Dual Epidemics – State Strategies to Prevent Flu during COVID-19
Strategic planning for the 2020-2021 flu season during the COVID-19 pandemic is critically important to ensure that states do not experience dual epidemics this year. In this November, 2020 webinar, NASHP, in partnership with AcademyHealth and Immunize Colorado, provided a national overview of flu prevention priorities from the Centers for Disease Control and Prevention (CDC), and a closer look at state strategies in Arizona and Illinois.
Speakers discussed how states can ensure equitable access to the flu vaccine, including expanding access to immunizations through pharmacies and other delivery sites to reach vulnerable populations, and various payment and reimbursement strategies. This webinar was funded by the CDC.
Participants included:
- Moderator: Jill Rosenthal, MPH, NASHP Senior Project Director
- Sam Graitcer, MD, CDR, Medical Officer and Pandemic Influenza Coordinator, Centers for Disease Control and Prevention
- Jami Snyder, MA, Director, Arizona Health Care Cost Containment System
- Ngozi Ezike, MD, Director, Illinois Department of Public Health
States Work to Advance Racial Equity in COVID-19 Outcomes and Beyond
Disparities in states’ COVID-19’s health outcomes have driven home the need for policymakers to reassess their work to advance racial equity and redirect efforts to be more effective. A recent update to the National Academy for State Health Policy’s (NASHP) interactive map, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, reveals that more than half of all states are now actively engaged in advancing equity in their COVID-19 responses and beyond.
States are working to ensure equitable distribution of resources and funding to promote health and safety for all during the COVID-19 pandemic. Some states are also beginning the long-term work of addressing systemic racism and other root causes of the disparities illuminated by the pandemic.
As the pandemic progresses and reveals the disproportionate impact of the disease on people of color, several states have created task forces and workgroups to ensure the equitable distribution of testing, personal protective equipment (PPE), and information about the disease. Some states are funding these efforts to better achieve equitable health outcomes for communities of color.
In Maine, for example, Black Mainers represent about 1.4 percent of the total population, but over 22 percent of the COVID-19 cases whose race is known. Gov. Janet Mills announced that $1 million from the Coronavirus Relief Fund would be dedicated to expanding services like testing, case investigation, contact tracing, and education to help reduce the disproportionately large racial and ethnic disparities in COVID-19.
As the recommendations and findings from the state task forces are published, one theme that emerges is the need for states to engage with communities and prioritize the needs they identify. The examples below underscore a critical lesson that states have learned from COVID-19 – their prior strategies to advance equity were not sufficient and integrating community feedback is essential to forge new and effective strategies. These recommendations reflect the importance of involving communities and people of color in states’ long-term policies:
- In New Hampshire, the COVID-19 Equity Response Team released its initial Report and Recommendations in which they described the need for proactive community engagement, working toward an ideal of co-creation and community ownership.
- In Oregon, the Equity Framework in COVID-19 Response and Recovery features a commitment to make community-informed policy and forge partnerships by engaging with community leaders who should be an essential part of the decision-making process.
- In Washington State, proposed recommendations from the Governor’s Interagency Council on Health Disparities include the provision of opportunities for communities to take the lead in creating information about and for themselves, including through contracts and grants.
- In Virginia, Gov. Ralph Northam announced a pilot program in Richmond to increase equitable access to PPE in underserved communities that may be more adversely impacted by the COVID-19. The pilot program includes community engagement events and training on cultural humility and implicit bias for city personnel who engage with the community.
The themes of including communities in decision-making and in the crafting of emergency responses are reflected in state funding streams as well, with some states providing funds to community groups. The Utah COVID-19 Community Task Force created a multicultural subcommittee that oversees the COVID-19 Racial Equity & Inclusion Grant Fund. The fund provides grants up to $5,000 to community-based organizations that provide emergency assistance to multicultural communities. In Michigan, $20 million was made available to the Coronavirus Task Force on Racial Disparities to respond to community needs associated with the disparate impacts the virus has had on communities of color. Community groups were able to apply for the funding through the Rapid Response Initiative, with funds available for a wide range of needs.
As states continue to work towards equitable health outcomes and look for ways to counter a long history of systemic racism, several are focusing on children’s health as a way to address disparities and potentially influence health trajectories in the future. For example:
- New Hampshire’s Equity Response Report recommended Adverse Childhood Experiences (ACEs) as an area to explore to continue understanding and serving communities of need in New Hampshire, specifically communities of color, at both the state and local levels.
- Ohio’s COVID-19 Minority Health Strike Force Blueprint highlights strategies to improve health outcomes and advance equity for children, including strengthening early childhood education and specifically ensuring that K-12 chronic absenteeism reduction efforts meet the needs of children of color. Ohio’s Plan to Advance Equity highlights how childhood poverty disproportionately affects African American and Latinx children in Ohio. To address this, the governor established the Office of Children Services Transformation within the office of Children’s Initiatives and is investing $675 million to assist students’ wellness and success.
The COVID-19 pandemic is far from over, and the effectiveness of these strategies will be evaluated based on how well they reduce disparities in COVID-19 outcomes and the advancement of health and social equity beyond the pandemic. NASHP will continue to engage states in identifying promising practices and will provide tools and support as states implement their task force and workgroup recommendations and measure change and success over time.
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.
States Need Federal Guidance to Plan for When the Public Health Emergency Ends
While the federal COVID-19 public health emergency – which allows for a range of state and federal policy flexibilities in programs such as Medicaid – was recently extended, considering the significant number of pandemic-related policies that states have implemented, officials need to begin preparing now for the eventual end of the emergency. Currently, there is little federal guidance about how states would unwind the many policy changes they have implemented in response to the pandemic.
In addition to the absence of directions detailing how states can return to pre-public health emergency (PHE) operations, states are still challenged by the economic effects of the pandemic, including significant declines in revenue that have depleted many state budgets. Meanwhile, thousands of individuals who have lost income or employer insurance coverage have enrolled in Medicaid, imposing an additional strain on state resources.
During the National Academy for State Health Policy’s 2020 annual conference and in recent discussions with leaders, state policymakers have expressed the need for ample time and federal guidance to prepare for the end of the PHE. A letter sent by the Medicaid and CHIP Payment and Access Commission (MACPAC) in late August to Department of Health and Human Services (HHS) Secretary Alex Azar echoed these concerns and also raised the issue that some state Medicaid agencies may need state legislative approval for certain program changes required to transition back to pre-PHE operations.
MACPAC recommended that federal officials should provide states with a minimum 90-day advance notice of the PHE’s termination, and that federal guidance about returning to regular processes should be provided to states as early as possible.
One of states’ key concerns is disenrolling individuals from Medicaid who may have become ineligible during the PHE. This is because the Families First Coronavirus Response Act (FFCRA) provided enhanced federal Medicaid matching funds tied to maintenance of effort (MOE) requirements that include a prohibition on terminating Medicaid coverage of individuals who were enrolled as of or after March 18, 2020. To comply with that requirement, often referred to as the “continuous coverage” provision, states are not fully processing their traditional Medicaid renewals. The purpose of this MOE requirement is to help prevent coverage disruptions, particularly at a time when consumers may be especially in need of coverage, yet also experiencing extreme fluctuations in income.
Although the increase in federal Medicaid funds provided by the FFCRA and the other MOE requirements do not expire until the end of the quarter in which the PHE ends, the continuous coverage provision ends on the last day of the month of the PHE. However, due to a number of reasons, states will not be able to immediately return to the regular processing of eligibility renewals. As noted by MACPAC, restarting these processes will require states to collect new information about enrollees’ income and other criteria to re-verify eligibility. To do so, states will need to make a number of eligibility system, policy and process changes.
States have emphasized the need for flexibility when reinstating eligibility redeterminations. For one, changes will need to be implemented within the context of strained state administrative capacity due to budget cuts, staff furloughs and reassignments to other departments to respond to COVID-19, early retirements, hiring freezes, and the need to focus on addressing increased demand for state-supported services. States also have different IT systems for determining Medicaid eligibility, each with distinctive programming challenges. This is further complicated by the fact that systems must be coordinated, and in several cases fully integrated, with health insurance marketplaces, a major vehicle through which consumers may seek Medicaid and marketplace coverage. Given these complications, states have expressed the need for a “menu of options” from the Centers for Medicare & Medicaid Services (CMS) detailing how to phase out the changes put in place during the PHE. Requirements for notifying enrollees about program and eligibility changes also vary by state, and states need time to develop notices and send out information to both individuals and providers about coverage changes.
Another important issue is that because the renewal process is currently backlogged, it could overwhelm states if federal officials require them to go back and process redeterminations for individuals with renewal dates that have already passed. In anticipation of the eventual end of the PHE, some states have been continuing to send out renewal notices to enrollees to gather and assess their information. In these states, coverage for eligible individuals is extended and while no action is taken to disenroll those who appear to be ineligible, they can be identified for follow-up at the end of the PHE. But many state officials have indicated that it would be helpful if federal guidance instead allows them to focus on moving forward with a rolling renewal date process when the PHE expires.
Colorado’s Department of Health Care Policy & Financing recently sent a letter to CMS administrators requesting certain federal actions to help it plan for the end of the PHE. Specifically, the state asked that CMS provide at least 60-days notice before the end of the PHE, and allow at least 90 days after the end of the PHE to conduct redeterminations and inform enrollees and providers about the associated changes — and it indicated that even more time may be needed if the PHE is extended beyond October because Medicaid enrollment will likely continue to increase over time. Similar to MACPAC, Colorado also stressed the importance of CMS providing specific guidance about redetermination requirements, and they requested additional guidance about aligning redetermination time frames between CHIP and Medicaid. Because Colorado’s pause on processing renewals in CHIP was implemented through a state plan amendment (SPA), its CHIP policies expire on the day that the PHE ends, as opposed to the Medicaid continuous coverage provisions, which expire on the last day of the month in which the PHE ends.
Colorado’s letter also emphasized that the state has at least 40 Medicaid projects and 65 home- and community-based services items that will need to be modified when the PHE expires. Some of these efforts will involve significant changes in claims processing and eligibility systems that will take time to implement and increase the workload of eligibility technicians. Some of the other issues that the state is seeking guidance on from CMS include:
- Whether states will have flexibility to stagger redeterminations and renewals after the end of the PHE to reduce the workload burden; and
- Whether federal Medicaid funding will be available for enrollees for whom the state is conducting redeterminations on for beyond 90 days if the state needs more time, as well as through any disenrollment appeals processes.
The letter also raised an issue that has been expressed by state-based marketplace (SBM) officials in other states — that states will need time to develop messaging and provide assistance to individuals who are no longer eligible for Medicaid in order to help them enroll in marketplace coverage. Many SBM officials are concerned that once the PHE ends, they may face an unmanageable influx of individuals transitioning from Medicaid to marketplace coverage. As federal officials develop guidance, they should take this issue into consideration and also factor in the timing of SBMs’ open enrollment periods.
In addition to eligibility redeterminations, states will also need sufficient time and federal guidance to unwind other policies implemented during the PHE, such as Section 1135 waivers that eased many provider-related requirements and validations, and Medicaid and CHIP disaster relief SPAs to facilitate enrollment or waive cost-sharing requirements. Another factor is that some states may be interested in retaining certain policy flexibilities implemented under the PHE, and as identified by MACPAC this will require states to take a number of steps to make these changes permanent.
States will also need guidance about resuming many federal reporting requirements that were put on hold during the PHE. Given the pandemic’s wide-ranging effects on coverage and care access, state Medicaid and CHIP officials have expressed concerns about how to determine baseline data for quality measures and provide information for other regular program integrity assessments. They indicated that they hoped CMS would allow flexibility in 2020 and 2021 federal reporting and auditing as states make good-faith efforts to come into compliance. SBM officials have expressed similar concerns about the potential of being penalized for certain policy choices and the need for federal recognition of the unique programmatic and operational challenges created by the pandemic.
As highlighted by MACPAC, “Delayed guidance, unrealistic expectations, or short implementation time frames for eligibility redeterminations and provider revalidations could disrupt state operations, result in beneficiaries churning on and off of Medicaid coverage, and jeopardize access to care.”
Although the PHE was extended again, states still face significant challenges without sufficient information from the federal government about how to transition back to regular operations. States urgently need formal federal guidance so they can begin effective and efficient planning efforts now, both to reduce administrative burdens and minimize disruptions in coverage and care.
Stand by Me: Supporting Long-Term Services and Supports Workers
Direct care workers play a critical role in the success of states’ long-term services and supports (LTSS) systems, but faced with COVID-19, low wages, and few advancement opportunities, states struggle to retain this workforce. Recently, state leaders came together virtually at National Academy for State Health Policy’s annual conference to share strategies to improve recruitment and retention of these workers.
Today, personal care attendants, home health aides, and nursing assistants are on the frontlines, providing care to older adults and people with disabilities. COVID-19 has made direct care work one of the most dangerous professions, while putting an enormous strain on family caregivers and state budgets.
Even prior to the pandemic, states faced a significant direct care workforce shortage due to the low wages and limited advancement, which has contributed to high turnover. The pandemic has exposed other vulnerabilities – nearly six out of ten direct care workers are people of color and almost half live in low-income households.
Tennessee Promotes Workforce Retention
In 2013, the TennCare (Tennessee Medicaid) Long-Term Services and Supports (LTSS) division held listening sessions throughout the state and found that Medicaid enrollees’ quality of life hinged on the quality and consistency of their LTSS workers. That insight led state officials to create a value-based workforce strategy for direct care workers. Using a State Innovations Model (SIM) grant from the Centers for Medicare & Medicaid Services (CMS), the state incorporated workforce recruitment and retention into its value-based payment strategy, and worked across state agencies to implement and incentivize career and educational opportunities for direct care staff.
In consultations with national experts, the state developed a competency-based training program using evidence-based best practices in adult learning. Corresponding with CMS Direct Support Workforce Core Competencies released in 2014, the training uses an online format combined with work-based learning to provide an opportunity to acquire shorter-term credentials with clear labor market value.
Officials from TennCare worked with the Tennessee Board of Regents to award college credit and a post-secondary credential (certificate) for completion of the training. This curriculum is embedded within a variety of existing (and potential new) degree paths through the Tennessee Community Colleges and Colleges of Applied Technology. The state was also able to leverage Tennessee Promise and Tennessee Reconnect funds to defray tuition costs for adult learners, and plans to provide incremental raises to direct care staff who complete the training once the state weathers COVID-19-related budget shortfalls.
At the same time, TennCare has begun to transition its LTSS system to a value-based payment model. Staff training, retention, and job satisfaction are key measures in the state’s quality framework and tied to LTSS provider reimbursement. By aligning Medicaid payment, investments in workforce training, and the state’s higher education goals and resources, Tenncare has established a clear education and career pathway that will help it grow and retain its direct care workforce.
Oregon’s Home Care Workforce Unionized
Because of the relationship between direct care workers and quality of care, the state created the Oregon Home Care Commission, a semi-independent state commission that supports home care workers, personal support workers, and consumers/employers by:
- Defining qualifications of home care and personal support workers;
- Providing a statewide registry of these worker that matches individuals needing in-home care with home care workers;
- Providing training opportunities; and
- Serving as the “employer of record” for collective bargaining for home care and personal support workers who receive service payments that are from public funds.
The Service Employees International Union (SEIU), represents Oregon’s in-home workforce. Full-time equivalent in-home workers must earn an income above the poverty level for a family of four in Oregon. They have health benefits (for 40 hours of work per month) as well as leave time for vacation, sick time, and COVID-19. They also receive training and personal protective equipment (PPE).
The state funds Oregon Care Partners, an education resource that provides in-person and online classes to help family and professional caregivers build the knowledge and skills needed to improve the quality of life of older adults and people living with Alzheimer’s in Oregon. These classes are available to anyone living or working in Oregon and are offered free of charge. Classes include COVID-19 infection control, supporting individuals with Alzheimer’s/dementia, supporting individuals with challenging behaviors, cultural competency, and more.
Oregon’s support of its direct care workers through living wages, sick and vacation benefits, training, and a registry that matches these workers with individuals needing home care helps not only this important workforce but also care recipients and their families. This support has been an important strategy in this state’s longtime effort to successfully rebalance its LTSS system toward home and community-based services.
Looking Forward
Both Tennessee and Oregon have had to respond quickly and with enormous flexibility to the challenges presented by the pandemic, maintaining LTSS services through strategies such as provider rate increases and retainer payments, new infection control protocols, and additional protections and benefits for LTSS staff.
While cascading effects of both COVID-19 and state budgets make ongoing investments in the direct care workforce incredibly challenging, the experience of the past few months has also opened up new opportunities: Medicaid waiver flexibilities and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and state funding allowed states to increase payments to stabilize and incentivize the LTSS workforce to maintain care to some of the most vulnerable populations during the pandemic. Telehealth has been transformational. Certain services, such as therapies, care management, and adult day health, moved from face-to-face to virtual encounters. Some states used additional pandemic-related money to provide childcare for essential workers.
As a result of these unprecedented changes, state officials are rethinking how LTSS is delivered, where, and by whom. The future direct care workforce will likely need additional training on managing the spread of infectious disease, delivering care through telehealth and other virtual modalities, and engaging families as critical partners on the care team. State health policymakers may also want to invest in the LTSS workforce as another opportunity to address racial equity within state-funded healthcare systems. While it is too soon to tell which of the many changes wrought by the pandemic in state LTSS systems will be sustained, one thing is certain, as noted by a state health official during the NASHP conference: “Medicaid will never look the same after COVID.”
This conference session and blog is one component of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, which is funded by The John A. Hartford Foundation in collaboration with the Administration for Community Living.
With a Federal Eviction Moratorium in Place, States Develop Additional Protections for Low-Income Renters
Last week, the Centers for Disease Control and Prevention (CDC) issued an agency order temporarily halting residential evictions for nonpayment of rent due to COVID-19 through the end of 2020. This unprecedented action, which includes no provisions address landlords’ lost income, identifies housing as a key tool to prevent the spread of COVID-19. Alongside this federal action, states can implement additional initiatives to help low-income renters avoid eviction.
With more than 16 million Americans unemployed, 43 percent of renters were unable to pay their rent at the end of July. It is estimated that 19 to 23 million renters will be at risk of eviction by the end of September. Housing affordability is not a new issue in the United States, but one that is exacerbated by the COVID-19 pandemic. Prior to the pandemic, nearly 21 million renters were cost burdened – spending at least 30 percent of their income on rent. Individuals and families who rent have lower incomes than homeowners and are less likely to have savings to cover unanticipated expenses or emergencies.
The $2.2 trillion Coronavirus Aid, Relief and Economic Security (CARES) Act provided essential, one-time $1,200 stimulus checks, enhanced unemployment benefits, and a moratorium on evictions for renters in properties financed by federally backed mortgages. Analysis by the Urban Institute revealed the CARES Act protected 12.3 million renter-occupied, federally financed units, which account for one in four total rental units. The CARES Act eviction moratorium and the enhanced unemployment benefits expired in late July. The CDC eviction moratorium provides more protection for renters than the CARES Act moratorium by covering all rental properties.
The CDC agency order explained, “… housing stability helps protect public health because homelessness increases the likelihood of individuals moving into congregate settings, such as homeless shelters, which then puts individuals at higher risk to COVID-19.” Renters who declare they expect to earn less than $99,000 a year ($198,000 if filing jointly) are protected from eviction until Dec. 31, 2020. Renters will still be responsible for paying rent, including the unpaid “back” rent, after the order expires and can be evicted for other lease violations.
Before the CDC’s action, Moody’s Analytics estimated renters would owe nearly $70 billion in back rent by the end of the year. Moody’s estimate included 12.8 million renter households who would each owe on average $5,400.
While the CDC action protects renters, it creates economic hardship for landlords for whom that lost revenue is significant. A recent study found that over 50 percent of property owners manage four or fewer units, and rely on rent from their units for operating costs and income. A long-term reduction in rental properties could also jeopardize the affordable housing market — there is already a shortage of more than 7 million homes for low-income renters.
Housing and Health Equity
Access to housing is an important driver of health outcomes. Research indicates that eviction can lead to homelessness, housing instability, and increased use of emergency health care services. The threat of eviction is associated with negative mental and physical health outcomes including depression, high blood pressure, and child maltreatment. Eviction prevention can also save states money. In New York, keeping one family in a home saves taxpayers $68,422 per year in shelter costs.
Historically marginalized populations have experienced higher rates of COVID-19 infections and mortality, and are also more likely to be at risk for eviction. These inequalities are driven by structural racism and policies, such as redlining, that created barriers to homeownership for people of color. Today, nearly 70 percent of White residents own their homes compared to 42 percent of Black residents and 48 percent of Latinx residents. Black and Latinx workers are also more likely to be unable to work from home, making it more difficult for them to earn income to pay rent.
July 2020 data from the Household Pulse Survey reveals that more than 40 percent of Black and Latinx households had no or only slight confidence they could pay their rent next month compared to 21 percent of White renters. Additionally, in 17 states, Black women are twice as likely to have eviction notices filed against them as White renters. Eviction filing histories also make it more difficult for renters to secure rental properties in the future.
State Actions
With federal unemployment assistance expired and a federal eviction moratorium set to expire at the end of the year, states are providing additional protections and financial assistance to low-income renters. In March, 43 states and Washington, DC passed eviction moratoria, with more than half expiring by early August. States are now looking at other policy levers to protect low income renters and landlords through leveraging federal funding, executive actions, and legislation. The following states actions outlined below provide protections above the current federal moratorium and some provide landlords with direct financial assistance.
Leveraging federal dollars to support low income renters:
- In Arizona, the Department of Housing is partnering with community action agencies to assist renters through the Rental Eviction Prevention Assistance Program. Renters who have lost more than 10 percent of their income are eligible to apply. As of late August, 1,794 households were approved, representing 8 percent of total applications. The program is currently funded by $5 million dollars from the State Housing Trust Fund.
- The Illinois Housing Development Authority created the Emergency Rental Assistance Program with CARES Act funding directed to the agency from the General Assembly. The $150 million-dollar fund will provide eligible tenants one-time $5,000 grants paid directly to their landlords for missed rental payments or to cover upcoming rental payments through December 2020. The program is expected to assist 30,000 tenants this year.
- Michigan’s Eviction Diversion Program provides $60 million in CARES Act funding for rental assistance, case management, and legal services to support those with eviction filings. Rental assistance is income-based and allows for one-time payments up to $3,500.
- Montana used $50 million of its CARES Act dollars to create an Emergency Housing Assistance Program. Financing from the program caps family’s rent or mortgage contributions at 25 percent of their net income. As of late August the program had awarded approximately $2.5 million to reaching more than 830 Montanans with an average of three months of assistance and $2,822 per household paid to landlords and mortgage servicers.
- North Carolina Gov. Roy Cooper allocated $175 million federal dollars to support North Carolinians’ economic stability. Federal Community Development Block Grant Coronavirus funding ($28 million) and CARES Act Coronavirus Relief Fund ($66 million) dollars will be used to support rental and utility payments. Approximately $53 million from the federal Emergency Solutions Grant – Coronavirus (ESG-CV) program will be used to support the Department of Health and Human Services’ work on crisis response and housing stability.
- Pennsylvania created the CARES Rent Relief Program with $150 million dollars in federal funding. This program provides funding to localities to assist “lessees that became unemployed after March 1, 2020, due to the COVID-19 pandemic, or lessees that are experiencing at least a 30 percent reduction in annual income related to COVID-19.” The program provides funds directly to property owners for rent accrued from March 1 to Dec. 30, 2020. Monthly assistance is capped at $750.
- Wisconsin is leveraging $25 million dollars from the CARES Act to assist renters through the Wisconsin Rental Assistance Program. This program is a partnership between the Wisconsin Division of Energy, Housing and Community Resources and the Wisconsin Community Action Program Association. Renters with incomes below 80 percent of the county median income will be eligible for up to $3,000 per individual to cover rental payments and/or security deposits.
Implementing eviction moratoria through legislation:
- In California, Gov. Gavin Newsom signed legislation that prohibits evictions before Feb. 1, 2021 “as a result of rent owed due to a COVID-19 hardship.” Tenants must pay 25 percent of rent due to avoid eviction.
- In Massachusetts, legislators are considering H4878, which would create a moratorium on evictions and negative credit report filings until 12 months after the State of Emergency declared by Gov. Charlie Baker ends.
- Proposed legislation, S8667, in the New York Senate would place a moratorium on evictions for residential and commercial properties. The bill states, “… it is counterproductive to public health and welfare to allow evictions and foreclosures until the COVID-19 pandemic has passed and sufficient time has been provided for communities to recover.” Similar to Massachusetts, the bill extends the moratorium until one year after the public health emergency ends.
- In Virginia, the Virginia Supreme Court halted evictions until Sept. 7, 2020. State legislators are currently convening for a special session to consider a proposal to create a $3.3 million dollar Eviction Diversion and Prevention Pilot Program. Lawmakers will also consider a bill to pause evictions until April 30, 2021.
The financial impact of COVID-19 will extend far past 2020, with new research suggesting that 42 percent of recent layoffs could lead to permanent job loss. With the federal eviction moratorium in effect until Dec. 30, 2020, additional measures will be necessary to prevent evictions and housing insecurity for low-income individuals and families. Additionally, if the CDC order is successfully challenged in court, moratoria at the state level will become even more important to prevent evictions.
As states work to prevent evictions, there are a variety of other policy levers available to provide low-income individuals with assistance to find and maintain housing, often with the supportive services they need to maintain housing. The National Academy for State Health Policy Health and Housing Institute works with states across sectors on strategies to improve health and housing for vulnerable populations. Learn more about state work on improving housing and reducing homelessness at NASHP’s Housing and Health Resources for States.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. 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.
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. 
