Acknowledgements: The authors thank state officials from Mississippi, Kentucky, Wyoming, Washington, and Maryland who reviewed a draft of this publication. This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
State Strategies to Increase COVID-19 Vaccination Rates in Children
COVID-19 vaccines have been available for children ages 5-11 since October 29, 2021. As of March 16, 2022, the Centers for Disease Control and Prevention (CDC) reports that just one-third (33%) of children in this age group have received their first vaccine dose, with vaccination rates varying widely by state. Just twenty-six percent of 5–11-year-olds have been fully vaccinated.
The ten states with the highest fully vaccinated rates among children ages 5-11 years (Vermont, Massachusetts, Rhode Island, Hawaii, Maine, Maryland, Connecticut, Virginia, Minnesota, and Illinois) have adopted creative approaches to promoting COVID-19 vaccination.
This blog highlights several of these approaches, which states may consider adopting when encouraging parents to get their children vaccinated against COVID-19 and other vaccine-preventable diseases. These strategies may be extended to vaccination activities for 6-month to 4-year-olds once COVID-19 vaccines receive emergency use authorization for this age group from the U.S. Food and Drug Administration.
Incentives
Many states have offered incentives to encourage COVID-19 vaccination. These incentives range from college scholarships to free food, with mixed results when evaluated for impact on vaccination uptake. A randomized clinical trial in Sweden in 2021 demonstrated that monetary incentives increased vaccination rates by approximately 4 percent. Other research has suggested incentives are most effective when three criteria are met: receipt of the incentive is certain, incentives are delivered immediately, and the recipients value the incentives. Several states in the top 10 for vaccine coverage offered incentives for vaccinating children ages 5-11, including:
- Vermont created the School Vaccine Incentive Program in December 2021, which provides monetary awards to schools achieving an 85 percent student vaccination rate. Schools are awarded $15 per vaccinated student with a minimum award of $2000 and a maximum award of $10,000. Schools achieving at least 90 percent student vaccination rate can apply for an additional 50 percent of the initial award, up to a maximum award of $15,000. The state is using federal emergency funds to support the program, which runs through April 1, 2022.
- Minnesota launched its “Kids Deserve a Shot!” campaign, providing families with a $200 Visa gift card if their 5-11-year-old child received both doses of a COVID-19 vaccine between January 1 and February 28, 2022. More than 22,000 children registered to receive a gift card as a result of this program. On March 1st, the Governor announced that any Minnesota parent or guardian whose 5 to 11-year-old had ever received both doses of COVID-19 vaccine by April 11, 2022, can enter to win one of five $100,000 Minnesota College Scholarships. This strategy was modeled after the state’s successful program to vaccinate children ages 12-17.
- Six months after 12-17-year-olds became eligible, the state launched the program to help drive up vaccination in the youth population, which had the lowest vaccination rate at the time. Within one week of the start of the campaign, first dose vaccinations increased nearly 40%. The state offered a $200 Visa gift card for 12-17-year-olds who started and completed their vaccine series within a six-week window, and five drawings of $100,000 Minnesota college scholarships for any Minnesotan 12-17 years old with a complete vaccine series.
School-located Vaccination Clinics
States play an important role in the success of school-based COVID-19 vaccination clinics. States can support schools with coordination of efforts, financial support, and media outreach in addition to providing vaccination supplies, personal protective equipment, and personnel to support these activities.
- Virginia recently published a playbook to support school-based vaccination events. “Vaccination of the School-Age Population in a School Setting and in the Community: Playbook to Support Vaccination Events” was created in partnership with the state’s immunization coalition, Vaccinate VA, and provides information for planning and conducting school-located COVID-19 vaccination clinics for the 5- to 11-year-old population.
- Connecticut published its “#Vax2SchoolCT” toolkit, which outlined step-by-step logistical considerations and recommendations for promotion and outreach. The toolkit provides a letter template for communications to students and families as well as information on the state’s “Vaccine+ Program,” which connects families to resources such as water and heating assistance.
- In Hawaii, schools were the main staging ground for administering COVID-19 vaccinations to children ages 5-11, with over 100 public, private, and charter schools holding vaccination clinics.
- Illinois organized 756 elementary school districts to offer vaccination clinics for students ages 5-11 on school grounds. Their mobile vaccination teams conducted more than 870 school and youth events when vaccines became available for 12-17-year-old students.
Parent-friendly Websites
States can provide public-facing information that is easy to access and navigate and that makes choosing to get vaccinated the easy choice. Several states have webpages dedicated to COVID-19 vaccinations for children.
- Vermont’s dedicated website for pediatric COVID-19 vaccines, “Just for Them!”, provides an online consent form and pre-vaccination checklist translated in many languages. Twenty-five percent of Vermont’s 5–11-year-old population registered to receive a vaccine within eight hours of opening registration to the public.
- Minnesota posted their “COVID-19 Vaccines and Kids: What Pediatricians Are Saying,” video to the state’s website, providing information to parents who may be hesitant about getting their children vaccinated.
- Massachusetts has a dedicated website for COVID-19 vaccines for 5-11-year-old children that includes a downloadable consent form, answers to frequently asked questions, and includes a chatbot that can answer COVID-19 vaccine-related questions in real time.
Partnerships
States can partner with organizations such as their state chapter of the American Academy of Pediatrics, state and local immunization coalitions, and hospitals to help build confidence in COVID-19 vaccines and improve access to vaccination for children. For example:
- Vermont and the Vermont Chapter of the American Academy of Pediatrics partnered to provide Facebook live “Chapter Family Forum” events featuring Vermont pediatricians who discussed the importance of vaccinating children against COVID-19.
- Rhode Island and Lifespan’s Hasbro’s Children’s Hospital partnered to provide hospital-based COVID-19 vaccination clinics for children ages 5 to 11.
- Minnesota partnered with the Mall of America to vaccinate children. The Mall of America clinic had the capacity to vaccinate 1,500 children per day.
- Massachusetts partnered with museums such as the Discovery Museum in Action, Boston’s Museum of Science, and the EcoTarium Museum to offer age-specific vaccination clinics for younger children.
- Illinois announced that the Illinois Department of Public Health had “reached out to every pediatrician in the state to enroll them in the vaccine distribution program” and then called on parents to call their pediatricians and make sure they had enrolled and ordered doses. The state enrolled more than 2,200 locations to provide vaccinations to 5-11-year-olds, including more than 700 medical practices, more than 700 pharmacies, 100 urgent care centers, 112 local health departments and public health clinics, 270 federally qualified health centers, more than 200 hospitals, and dozens of rural health clinics.
Media
Federal funding has provided states with unprecedented opportunities to create media messages promoting COVID-19 vaccinations for children. States can play a vital role in building vaccine confidence and promoting vaccination for children through media. Examples of such messages include:
- Vermont partnered with Vermont Public Radio’s “But Why: Podcast for Curious Kids” to explain the importance of kids getting COVID-19 vaccines and hear from kids who took part in COVID-19 vaccine trials.
- Maine announced a contest for children ages 5 to 17 to create a short video that explains the benefits of getting the COVID-19 vaccine or the risk of not getting vaccinated. The first place winner was awarded $50,000 for their school, with $25,000 going to second place and $10,000 to third place. Schools can use the prize money to supplement school meals with healthy treats; purchase playground, classroom, gym, sports, or music equipment; enhance a special school activity; or support a school field trip for all students.
- Maryland partnered with the Maryland Chapter of the American Academy of Pediatrics to create a public service announcement featuring pediatric health care providers from around the state who encourage parents to get their children vaccinated against COVID-19.
- Illinois, in partnership with the Illinois Chapter of the American Academy of Pediatrics, created a COVID-19 Pediatric Vaccine Social Media Toolkit to provide credible, informative, and diverse social media messaging to promote COVID-19 vaccination for children ages 5 years and older. The toolkit included pediatric vaccination flyers, social media digital resources, and videos, including a video from the director of the Illinois Department of Public Health, Dr. Ngozi Ezike, who is a board-certified internist and pediatrician and the first Black woman appointed to lead the agency.
With FDA emergency use authorization of COVID-19 vaccines on the horizon for children ages 6 months to 4 years-old, states will need to continue to find new and innovative approaches to encourage parents to vaccinate their children and to ensure vaccinations are readily accessible.
Moving Toward Prevention: Oregon Launches Kindergarten Readiness Metric
Oregon has launched a new kindergarten readiness metric in its Medicaid program. Early childhood is a critical time for growth and development, and the services and supports children and their families receive early on can have a large impact on health outcomes later in life. Because COVID-19 has exacerbated existing health disparities, including for young children, state officials are looking for new ways to support healthy child development and advance health equity. Oregon has promoted healthy child development for decades, with a particular focus on the social-emotional health of young children. The state’s new kindergarten readiness incentive metric focused on social-emotional health renews that commitment and helps solidify the connection between a child’s health and their success in school and beyond.
In the 2000s, Oregon worked with the National Academy for State Health Policy (NASHP) in the Assuring Better Child Health and Development (ABCD) Program. One of the state’s major goals at the time was to increase developmental screening for young children. One of the levers Oregon used to achieve this goal was to include developmental screening as an incentive measure for coordinated care organizations (CCOs)—a successful approach that led to one of the best developmental screening rates in the country. At that time, there was also interest in outcome-based kindergarten readiness metrics and a sense that CCOs could help ensure that children have their health-related needs met before entering the school system. NASHP staff recently interviewed state officials in Oregon about how the state has progressed from incentivizing developmental screening to creating a kindergarten readiness incentive measure that prioritizes children’s social-emotional health.
Kindergarten Readiness and Social-Emotional Health
For many children, kindergarten is their first contact with the education system. Those who arrive in the classroom with the skills and supports they need are more likely to have a positive experience, to succeed in school, and to have a healthy life. With the leadership of the Children’s Institute in collaboration with the Oregon Health Authority and Oregon Pediatric Improvement Partnership, Oregon formed the Health Aspects of Kindergarten Readiness Technical Workgroup in 2018 to identify the health aspects of kindergarten readiness and to offer recommendations about how to measure them. The workgroup, which was made up of pediatricians, early learning partners, families, and others, identified physical, oral, developmental, and social-emotional health as key aspects of kindergarten readiness in a 2019 report. The workgroup identified a need for systems-level change with social-emotional health as a priority focus area.
In conversations with NASHP, stakeholders in Oregon described unidentified or untreated social-emotional health delays as a factor that contributes to long-term educational inequities by increasing both the likelihood of classroom behaviors that are viewed as difficult and the likelihood of disciplinary action. Additionally, national data shows that children of color, particularly those who are Black or Indigenous, are more likely to have one or more adverse childhood experiences (ACEs) than white children—which can negatively impact social-emotional development. An Oregon health official shared that when children have ACEs and also experience racism, the supports available are often not matched to cultural needs and the response to social-emotional delays can further perpetuate health inequities.
In Oregon, children with social-emotional delays are not as likely to receive follow-up care as children who screen positive for other health needs. The Oregon Pediatric Improvement Partnership (OPIP) has led improvement work in 13 counties to focus on follow-up to developmental screening and consistently found that children with social-emotional delays rarely received follow-up services and a contributing factor is the lack of services available for children birth to age five.
Development of a CCO Incentive Measure for Kindergarten Readiness
In Oregon, the Medicaid CCOs, the state’s version of an “accountable care organization,” share financial and medical responsibility for physical, behavioral, and oral care with the state for providing coordinated care in order to limit unnecessary spending. The Oregon Health Authority (OHA) provides CCOs with a fixed global budget that allows them the flexibility to implement new ways of paying for and delivering care, using strategies that are best suited for their members. In addition to standard performance measures, a set of incentive measures is linked to a CCO quality pool fund. CCOs must meet benchmarks for performance on these measures to be eligible for incentive payments from the quality pool.
The Health Aspects of Kindergarten Readiness Technical Workgroup was tasked with identifying and assessing existing kindergarten readiness metrics to identify gaps and ultimately recommending metrics that could address health and be part of the CCO incentive measure set. After the 2019 measure recommendations were unanimously endorsed by state measurement committees, in 2020, Oregon began implementing readily available incentive metrics for children’s preventive dental and well-child visits. Then, informed in part by the OPIP pilot programs and the lack of services to address children’s social-emotional needs, the group recommended that CCOs work to incorporate a child-focused social-emotional kindergarten readiness incentive metric. The group recommended a strategy for building capacity to provide follow-up services and care: the suggested incentive measure would first require CCOs to do the community outreach and planning to develop needed resources and strengthen connections to services.
A team made up of individuals from the Children’s Institute and OPIP developed the novel metric, which was supported by the Oregon Health Authority. The team presented a proposal to Oregon’s Metrics and Scoring Committee in November 2020 and then carried out pilot activities with the CCOs in early 2021. The resulting Health Aspects of Kindergarten Readiness Measure: System-Level Social-Emotional Health Metric was endorsed a metric and is included in the 2022 incentive measure set. As the CCO Metrics 2020 Final Report shows, distribution of quality pool funds is based on the number of total incentive measures a CCO meets and the CCO’s size.
Implementation and Next Steps
The kindergarten readiness metric is transformative and anchored to community engagement, stakeholder input, and hearing from marginalized communities in order for the CCO to attest to completing specific activities. Over the four years that the system-level incentive metric is in place, the CCOs will be asked to complete activities that fall into four specific components that require:
- Social-Emotional Health Reach Metric Data Review and Assessment
- Development of an Asset Map of Existing Social-Emotional Health Services and Resources
- CCO-Led Cross-Sector Community Engagement
- Development of an Action Plan to Improve Social-Emotional Health Service Capacity and Access
The CCOs will engage communities, create asset maps to identify what services are available, and review data for populations with historical inequities—breaking out the data by ACEs, medical complexities, race and ethnicity, zip codes, and more. At the end of the first year, the CCOs will design an action plan with community input about where to focus improvements. Over the remaining years the CCOs will continue to track and analyze the data to identify barriers and facilitators and to inform the transition to a child-focused social-emotional kindergarten readiness incentive metric at the end of the fourth year.
A key focus is assessing how the data, asset map, community engagement, and action plans can be informed by and address the specific needs of historically marginalized populations. Oregon has adopted the strategic goal to end health inequities in the state of Oregon by 2030. Implementing strategies among young children that promote health equity and equitable educational achievement is one way that Oregon is working toward a more equitable future for all inhabitants. As children’s health, mental health, and development opportunities continue to be a primary focus of COVID-19 recovery efforts, incentive-based approaches hold great promise to eliminate disparities experienced by children from historically marginalized communities.
States Take Action to Address Children’s Mental Health in Schools
The COVID-19 pandemic has exacerbated rising mental health needs among children and youth. In addition to experiencing the human cost and social isolation brought upon by COVID-19, many children have lacked consistent time in classrooms. School closures and shifts to online learning have limited access to educational and social opportunities as well as mental health services. Since the onset of the pandemic, 38 states have enacted nearly 100 laws focused on supporting schools in their role as one of the primary access points for pediatric behavioral health care. These laws provide funding for school-based mental health services, strategic planning to improve school mental health systems, training and resources for school staff and students, and guidance for school policies. As children navigate the lasting impacts of the pandemic and policymakers prioritize youth mental health, states are certain to continue investing in and strengthening school-based mental health systems.
Background
In 2019, 16.5 percent of US children were estimated to have at least one mental health disorder, and the rates of adolescents who experienced persistent sadness or considered suicide both rose substantially from 10 years prior. The COVID-19 pandemic has only amplified these decade-long trends. The Centers for Disease Control and Prevention (CDC) has reported sharp increases in the proportion of children’s emergency department visits that are related to mental health. At the same time, youth utilization of mental health services has decreased, which may reflect families’ concerns in seeking non-emergency, in-person care given the risk of COVID-19 and shortages of available health care professionals working in children’s mental health.
The Biden Administration and key national organizations representing providers have intensified their focus on children’s behavioral health. In December 2021, U.S. Surgeon General Vivek H. Murthy issued a youth mental health advisory and released guidance for states in elevating policies to improve children’s behavioral health. The advisory included allocating more resources and technical assistance to school mental health systems as a key recommendation for state officials. In addition, in October 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association released a joint statement declaring a national emergency of child and adolescent mental health, calling upon federal and state policymakers to address key priorities for improving the state of children’s mental health.
School-based mental health care can improve access to mental health services, reduce risk, and improve mental health and academic outcomes for students. Additionally, when effectively designed, school mental health services may help to reduce racial and ethnic disparities in access to mental health care. Ideally, these services are delivered through a comprehensive school mental health system (CSMHS) which supportsprevention, early identification, and provision of services and treatment for students with mental health needs. These systems are increasingly important to help address children’s mental health needs, particularly during the pandemic.
Federal initiatives that support CSMHSs include the Health Resources & Services Administration’s School-Based Health Centers, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Project Advancing Wellness and Resilience in Education (AWARE), and the Department of Education’s School-Based Mental Health Services Grant Program. Additionally, SAMHSA and the Centers for Medicare and Medicaid Services (CMS) have developed joint guidance to support states in implementing effective payment and delivery models for school-based behavioral health services.
State Laws Enacted During the Pandemic to Support School Mental Health Systems
Based on a national scan of state legislation introduced during the pandemic (March 2020 to December 2021), NASHP identified 92 state laws that were enacted to support children’s mental health through schools. States have pursued a range of approaches including 26 states allocating federal and state funding to increase school-based mental health services, 12 states supporting strategic planning to improve school mental health systems, 24 states providing education and resources for school staff and students, and 10 states guiding school mental health policies. See the table below for a list of states that have enacted laws to support these strategies.
Supporting strategic planning to improve school mental health systems
Schools often face a range of challenges in supporting students’ mental health, including identifying and implementing best practices and coordinating across agencies. During the pandemic, 12 states enacted laws that support strategic planning to identify barriers and approaches to increase access to school-based mental health services.
- Arkansas’s HB 1689 (Act 802) established the Arkansas Legislative Study on Mental Health and Behavioral Health, which is required to study and develop a report on mental health screening and suicide prevention policies for children in schools. (Enacted October 1, 2021)
- Connecticut’s HB 6621 (Public Act No. 21-95) established requirements for the School Emotional Learning and School Climate Advisory Collaborative, which will develop a strategy to initiate collaborations with community-based mental health providers and support school staff in mental health and social-emotional learning. (Enacted June 24, 2021)
Allocating funding to increase school-based mental health services
Schools report that the most common limitation to providing mental health services for students is inadequate funding. Relatedly, many schools face challenges in engaging mental health providers, and few meet the recommended ratios of students to counselors, psychologists, and social workers. To alleviate this barrier, 26 states enacted laws to increase financial support for school-based mental health services. These measures include funding to reimburse and support school telemental health services and to hire school-based mental health providers.
- California’s AB 133 (Chapter 143) established the Children’s Behavioral Health Initiative, which includes grant funding for school-linked behavioral health services. (Enacted July 27, 2021)
- Massachusetts’ H 4002 (Chapter 24) appropriated funding for a pilot program for telebehavioral health services through schools. (Enacted July 29, 2021)
- North Carolina’s SB 105 (SL 2021-180) allocated funding from the American Rescue Plan Act to establish a grant program for schools to hire psychologists in response to COVID-19. (Enacted November 18, 2021)
Providing mental health education and resources for school staff and students
Teachers and school staff can often be more effective in supporting students’ mental health when equipped with information on mental health and best practices for prevention and early identification. Seventeen states enacted laws to provide mental health training and resources for school staff.
- Rhode Island’s SB 31/HB 5353 (Chapter 131) requires that school staff and students receive education on suicide awareness and prevention. (Enacted April 22, 2021)
- Virginia’s SB 1288/2299 (Chapter 452) requires that school counselors receive training in mental health, including mental health disorders, depression, trauma, and youth suicide, in order to be licensed and to renew their license. (Enacted March 30, 2021)
States have also supported schools in providing mental health education and resources directly to students and their families. Thirteen states enacted laws to support schools in providing mental health education and resources for students.
- Illinois’ SB 818 (Public Act 102-0522) requires that health education courses for students include information on mental health. (Enacted August 21, 2021) Illinois also adopted HJR 1, which encourages schools to provide mental health training and education for students. (Adopted June 1, 2021)
- Texas’ SB 279 requires schools to include crisis line contact information on all identification cards for students in grades six through twelve. (Enacted May 28, 2021)
- Washington’s HB 1373 (Chapter 167) requires all school websites to provide access to information and resources on behavioral health, including mental health. (Enacted May 3, 2021)
Guiding school mental health policies
While local school districts often have autonomy in implementing and administering policies and programs, states can provide guidance for these policies by issuing requirements and recommendations. Ten states have enacted laws to support schools in adopting innovative policies to address many of the unmet needs and gaps in youth mental health services exposed during the pandemic. These include requiring that schools allow mental health days or excused absences related to students’ mental health needs, delineate protocols around providing mental health services, and develop plans for responding to a student experiencing a mental health crisis.
- Connecticut’s SB 2 (Public Act No. 21-46) requires local boards of education to allow students to take up to four mental health days per school year. (Enacted June 16, 2021)
- Florida’s SB 590 (Chapter 2021-176) requires that school health services plans, which are jointly developed by county health departments and local school boards, indicate that school and law enforcement staff must attempt to contact a mental health professional for a student in crisis, and that behavioral health providers and school resource officers must attempt to verbally de-escalate crises. (Enacted July 6, 2021)
Conclusion
Children’s mental health has been and will continue to be a top priority for state leaders across both legislative and executive branches of state government. With COVID-19 exacerbating the challenges children are facing, there is much more work to be done. This blog summarizes the actions many states have taken from March 2020 through December 2021. However, many more states continue to consider legislation during the 2022 session. The National Academy for State Health Policy will continue to track state policies to support children’s mental health during and beyond the pandemic.
Summary of State Laws Enacted During the COVID-19 Pandemic to Support School Mental Health Systems (March 2020-December 2021)
| Approach | States |
| Supporting strategic planning | |
| Work group/task force | AR, CA, CT, HI, MA, MI, TX, VA |
| Data/assessment of needs | AR, CA, CT, MN, TX |
| Recommendations and standards | AK, CA, CT, HI, LA, ME, VA |
| Allocating funding to support school-based mental health services | |
| Mental health services* | AZ, CA, CO, CT, DE, IN, KS, MA, MD, ME, MI, MN, MT, ND, NJ, NY, OH, OR, PA, TN, VA, WA |
| Telemental health | CO, FL, IL, MA, MN |
| Providers | AZ, DE, KY, MI, NC |
| Providing mental health education and resources | |
| School staff | AK, AR, CA, CO, DC, IL, IN, KY, LA, MA, MN, ND, NY, OK, OR, RI, VA |
| Students** | CA, CT, IL, KY, RI, UT, WA |
| Crisis hotline printed on student IDs | AR, IL, IN, NJ, NV, SC, TX |
| Guiding school mental health policies | |
| Mental health days/excused absence | AZ, CA, CT, IL, NV, UT |
| Crisis response policies | FL, MA, NE, NV, OR |
Note: The states listed here have enacted laws during the COVID-19 pandemic that support these approaches. These laws may be sustaining existing programs/policies, or enacting new ones, and states may vary in their implementation progress. Other state laws may have been enacted that support school-based mental health, but the language of the act did not specify as such. Additionally, other states may have implemented these approaches through other policy mechanisms.
*This category does not include state laws that specifically fund telemental health services (these laws are included separately in the row below).
**This category does not include state laws that require crisis hotlines to be printed on student IDs (these laws are included separately in the row below).
State Strategies to Increase COVID-19 and Routine Immunizations in Advance of Back-to-School
Amidst changes in the COVID-19 landscape, including navigating surges due to new variants, states are working with local partners to prepare for and implement back-to-school plans, while also anticipating the need to adapt as the school year progresses.
As of August 2021, children ages 12+ are eligible to get vaccinated against COVID-19. Children under 12 are not yet eligible, but authorities anticipate approval by the US Food and Drug Administration (FDA) for a COVID-19 vaccine for children under 12 (5-11 years old expected first) in early to mid-winter. The FDA granted full approval for Pfizer-BioNTech’s COVID-19 vaccine for 16+, and Moderna and Johnson & Johnson are working on finalizing their applications for full approval. This full approval will likely lead to additional actions by states, local governments, employers, universities and others to provide education and encouragement to get vaccinated.
See our Resource Page on
Students’ Transition
Back to School
These factors along with an evolving set of vaccine mandates and mandate bans complicates public health mitigation plans, not only for vaccinating but for the full complement of tools that reduce spread, including health education, masking requirements, testing, and contact tracing. Additionally, intention to vaccinate and access to vaccines vary widely across the unvaccinated, with vaccination status of eligible children closely mirroring that of their parents.
Health and education officials simultaneously are planning for flu vaccinations and prioritizing catch up for routine childhood immunizations, required in many states for school, which lagged significantly during the pandemic as families followed social isolation and socially distanced recommendations.
NASHP convened a group of state officials from across the country to exchange strategies and creative approaches to navigating this environment in various demographic, political and policy environments. This brief summarizes key themes around accelerating routine vaccination rates and increasing access to the COVID-19 vaccine among eligible youth, including making vaccines convenient, using data to target resources and effectively engage partners, partnering to increase access and address intent, and prioritizing equity.
Making Vaccines Convenient for Families
Making vaccines available at locations that align with individuals’ daily routines enables those who may have limited time or resources due to childcare responsibilities, transportation, and other barriers to become vaccinated against COVID-19. Such convenience is critical to promoting widespread access generally and is an important tool in advancing equitable access for school-age children who rely on caregivers.
Convenience can be achieved by making vaccines available in community settings. To target adolescents and their families, some states are offering vaccine clinics at schools, ensuring that families can have ready access in a community hub and trusted location. Several states are pursuing strategies to ensure people “stumble into” opportunities to vaccinate, through pop up clinics in highly populated places (such as transit centers), on school grounds, or other at popular community events to allow for families to get vaccinated together, like at state fairs (such as Wyoming’s Frontier Days), or sporting events. This type of broad access in community enjoys the benefit of enhanced vaccine confidence when delivered in collaboration with trusted sources.
Another key method for reaching unvaccinated populations is to engage community providers and ensure they are willing and able to administer COVID-19 vaccines, which is particularly important for those living in underserved or rural areas. Most Americans trust doctors, nurses, and pharmacists, especially their own, and states are leveraging this trust and engaging these providers in both COVID-19 and routine vaccination efforts. Early in the pandemic, Kentucky state officials partnered with the Kentucky Board of Pharmacy to encourage pharmacist participation in delivering COVID-19 and routine vaccines. The Department of Public Health, the Kentucky Immunization Registry Coordinator, and the Emergency Preparedness Pharmacist from the Kentucky Pharmacists Association enrolled community and independent pharmacies to participate in the state’s vaccination program to reach underserved populations. Pharmacies are now one third of enrolled COVID-19 vaccine providers in the state, with 482 participating locations.
Prior to the delta surge, states had closed most mass vaccine sites in favor of local clinics, individual demand for vaccines had plateaued, and officials began managing excess doses about to expire. However, many community providers remained reluctant to provide COVID-19 vaccines for several reasons, including being unable to use large quantities of vaccines. To address these challenges, a number of state health officials established distribution programs – breaking down large palettes of vaccine sent by the federal government into small quantities to be distributed to providers. This approach is key to reaching underserved populations through trusted health care providers. For example, the Virginia Department of Health (VDH) federally funded Small Shipment Redistribution Program allows medical providers to order doses using VDH’s vaccine management platform, and a network of distribution centers across the state are used to store and distribute doses to clinics. Mississippi set up a Pfizer vaccine distribution site at County Health Departments using CDC supplemental funds and deployed pharmacists to distribute smaller doses (minimum of 6) to local providers, clinics, pharmacies, and homeless shelters, allowing for broader access to individuals. Kentucky doubled the size of their COVID-19 Vaccine and VFC (Vaccines For Children) program field representative workforce to redistribute doses around the state directly to providers.
Encouraging Vaccines Holistically
States are also taking advantage of the CDC guidance allowing COVID-19 and routine vaccines to be co-administered and are co-locating vaccination clinics. Many states are focusing messaging campaigns to educate individuals and families about the importance of getting all appropriate vaccines, including the COVID-19 vaccine, flu vaccine, and other routine childhood vaccines.
Mississippi uses an opt-out model to encourage higher compliance for recommended routine vaccinations. For example, to exempt their children from receiving the HPV vaccine, parents are provided education and must sign a document acknowledging the health risks of not receiving the immunization. This model helped increase county HPV immunization rates from 45% to 71% between 2018 and 2019, and officials are considering extending this model to other routine vaccinations.
Data to Identify Need and Share with Partners
States identify having comprehensive data as a critical step in their ability to target strategies to increase routine vaccinations and COVID-19 vaccinations. All states use immunization information systems (IIS) to collect and communicate immunization data, but access to and use of the data varies. For example, some state’s IIS are connected to hospital electronic health records (EHR), and other states share data between IIS and Medicaid data systems. Some data sharing occurs regularly and automatically, and some require manual matching, which is a common challenge as this is more time-consuming for staff who may already be working at maximum capacity. It can be useful to increase data sharing and analytic capacity for states to allow connected EHRs and Medicaid data systems, as Medicaid serves as a healthcare provider for so many children.
States cited IIS data sharing as critical to identifying students who have not yet been vaccinated. The EHR and Medicaid connection is a key component to this strategy; having as much data as possible can help inform vaccination rates by enabling better targeting. Some states allow schools and school nurses the ability to pull data from the IIS so they can identify which students need their vaccines and target communication strategies based on this information.
Partnerships to Increase Access and Address Intent
Engaging trusted community leaders as messengers is essential to increasing vaccine intent. States are enlisting various community partners to help them engage more individuals in vaccination efforts. Vaccine intent varies across different demographic groups, and states can partner with school staff, healthcare professionals, and community and faith leaders to tailor vaccination engagement approaches.
Schools are important partners when it comes to hosting vaccine clinics and educating families about the importance of getting vaccinated. Mississippi and Kentucky designed school-based programs that bring vaccines to students who are eligible for the COVID-19 vaccine. Mississippi’s Adopt-a-School model incentivizes medical providers to coordinate on-site vaccination clinics at schools by paying participating providers $75 per shot. The Adopt-a-School program is part of Mississippi’s Covid-19 Community Vaccination Program, which is funded through a Center for Disease Control and Prevention (CDC) immunizations grant. The Kentucky Department for Public Health is contracting with a private vendor to host mobile vaccine clinics at schools. The state reimburses this vendor $80 per shot using FEMA (Federal Emergency Management Agency) funding. Other states are exploring partnerships between FQHCs and schools as well as public health and school nurses to organize school-based vaccine clinics.
Several other states are partnering with schools to circulate vaccine messaging and encourage students to get vaccinated. One state is collaborating with the American Academy of Pediatrics (AAP) chapters, school nurse organizations, and health and education departments to distribute information to students and families about vaccines. Other state officials from Kentucky and Maryland emphasized the important role of athletic departments in incentivizing vaccinations, as some schools do not allow unvaccinated students to participate in sports and ensuring the ability to take part in school athletic events is highly motivating.
State public health agencies can also engage more individuals by integrating vaccine efforts into the healthcare system. State health departments partner with primary care providers (PCPs), pharmacists, Medicaid agencies, and managed care organizations (MCOs) to educate individuals about COVID-19 vaccines and incentivize vaccinations. For example, one state’s Medicaid agency sent a fax blast to Medicaid-participating pharmacies to help encourage vaccinations. Another state official cited their state’s partnership with MCOs, where the MCOs helped organize community vaccination events and partnered with providers to increase vaccine availability. Other MCOs are offering financial incentives to their patients who get the COVID-19 vaccine. Trusted medical providers have a unique role in counseling and educating individuals about the safety of vaccines. Several states are leveraging this trust in doctors and creating initiatives that encourage providers to administer both COVID-19 and routine immunizations at doctor’s visits. For example, Wyoming is organizing a series of webinars for providers, giving them the opportunity to ask questions and work through challenges together.
Consistent Outreach and Messaging is Critical
States highlighted the value of a governor’s role in messaging through use of the bully pulpit including publicly vaccinating their eligible children. Still, most noted that effective outreach to those who remain unvaccinated requires tailored messaging to specific audiences and thoughtful assessment of population-specific barriers to vaccine information and uptake. Wyoming, for example, launched a multi-pronged messaging campaign to address vaccination holistically (including COVID, influenza and routine vaccinations). The campaign is tailored to the needs of various populations such as American Indians and residents in the most rural parts of the state. Intentional use of “choice” language through their provider and consumers educational campaigns has been key. Notably, early in the pandemic, some individuals were getting information about vaccine (and testing) opportunities across state lines which challenged state-specific messages around resources. The state responded through multiple messaging media to bring the right information to state residents.
Maryland is focusing outreach efforts to pockets of the state with a high rate of unvaccinated individuals. They are rolling out a voluntary screening/testing program at schools (reaching approximately 80% to date) with the hope of integrating mobile vaccination clinic opportunities into the program. The state is also aiming to reach areas with high need by leveraging multiple messaging strategies, such as door-to-door canvassing, pop up activities, digital communications, and partnerships with local employers and court systems.
Using an Equity-driven Approach
Given the disparate impact of the pandemic on communities of color, specifically Black, LatinX, and Indigenous groups, states are working to make sure their vaccine distribution strategy is equitable to these populations. Research shows that even though children may not have been impacted by the pandemic at the same rates as adults, the socio-emotional and developmental implications are staggering. And, children are experiencing similarly disproportionate levels of vaccine distribution, highlighting the importance of using an equity-driven approach to close the gaps in vaccine distribution in advance of and during the school year, and to mitigate the effects of the COVID-19 virus, especially with the emergence of the highly contagious Delta variant.
State officials cited their focus on areas with high numbers of unvaccinated people, as well as those vulnerable to infection. States use various data, such as the CDC’s Social Vulnerability Index (SVI), to identify these pockets of need and bring vaccinations to these areas, using a combination of mobile vaccination teams and local providers. Ensuring providers have appropriate educational materials and support to build vaccine confidence with their patients is critical.
State officials acknowledged efforts to engage community-based organizations and faith leaders to support vaccine intent. Kentucky created a COVID-19 vaccine communication toolkit for local trusted leaders to use when engaging with community members. There has also been an increased push from the federal level to address equity in COVID-19 response, including vaccination efforts. For example, the White House has increased public messaging and created the COVID-19 Health Equity Task Force and there has been an increase in equity-related funding from the CDC and HRSA to aid states as they work to use an equity lens on targeted approaches to vaccinate individuals.
Considerations for the Evolving Landscape
Several key themes were discussed without clear policy solutions and represent areas of continued opportunity as the school year begins and the vaccine landscape will continue to evolve:
- Navigating the issue of parental consent: Maintaining policies around consent for vaccination emerged as a major challenge in some states. A small subset of states allows minors 14 and older to consent for their own medical care through policies developed in partnership with provider organizations, such as the American Academy of Pediatrics. Political and policy disagreements with respect to exercising this option around the COVID-19 vaccine has resulted in clearer guidance from some states that parental consent is needed for COVID-19 vaccination separate from routine use of the minor consent option for other services.
- Incentivizing provider participation: Provider reimbursement approaches continue to evolve to incentivize vaccination and engage various provider types and locations. State officials noted further that provider reimbursement approaches should reflect the extended counseling sessions often occurring with unvaccinated people uncertain about their intention.
- Planning for the next milestones in vaccine approval: Several anticipated milestones will renew discussions around vaccine intent, access, and planning, including emergency use authorizations (EUA) for use of vaccines in children under 12 as well as full approval of those vaccines under EUA for adults and older children.
- Integrating pharmacists into vaccination efforts: Many states were eager to identify ways to include pharmacists in the Vaccines for Children (VFC) program specifically (and new adult immunization programs) to broaden the network and reach of vaccine providers, particularly in rural, frontier and otherwise underserved areas.
As students head back to school and state officials and providers continue to promote the importance of routine immunizations and the COVID-19 vaccine for eligible children, NASHP is continuing to follow this topic. For more resources on state policies to support students and families as they transition back to school, click here, and for more information on routine childhood and COVID-19 immunization services and policies, click here.
Advancing Access to Oral Health Care Amidst COVID-19 Recovery
Oral health is central to overall health, yet 34 percent of Americans lack access to affordable dental care, a challenge exacerbated by the COVID-19 pandemic. The pandemic disrupted oral health care in several ways. Early on, dental providers faced office closures and lacked personal protective equipment (PPE). Similarly, school-based dental sealant programs were inaccessible with school closures, limiting preventive care for school-age children from low-income families. These barriers led to an overall decrease in preventative and routine dental procedures. Dental care remains children’s greatest unmet health need during the pandemic, disproportionately affecting households with pandemic-related income and job loss. As a result of COVID-19, a shortage of dental assistants, hygienists and other team members is hindering the dental sector’s ability to recover and resume care.
In June 2021, the National Academy for State Health Policy (NASHP) convened a group of Medicaid and public health state leaders to discuss strategies and considerations for increasing access to oral health services amidst recovery from the COVID-19 pandemic. Participants identified teledentistry, school-linked programs and new federal funding available under the American Rescue Plan Act as key opportunities to increase access to oral health care.
Teledentistry
Participating state officials expressed their interest in increasing access to oral health care by sustaining or building on new teledentistry flexibilities introduced during the pandemic. According to the ADA, teledentistry, like other telehealth services, involves “the use of telehealth systems and methodologies” in dentistry, such as live video interaction, asynchronous or “store and forward” communication, and remote patient monitoring. Adoption of these methods and reimbursement for teledentistry approaches varies by state. Teledentistry can greatly increase access to oral health care, particularly for underserved populations such as communities of color and those living in rural areas.
During the pandemic, 17 states updated their Medicaid teledentistry guidance to allow new provider types to deliver virtual services, expand the scope of services that can be reimbursed through Medicaid, and ease consent restrictions that limited access to teledentistry, among other policy modifications. Considering telehealth policy revisions made during the COVID-19 pandemic, twenty-three states currently have policies in place to allow for delivery and reimbursement of teledentistry, however, challenges remain. For example, state leaders shared concerns about reimbursement for teledental services and limited guidance for providers about scheduling teledentistry visits in tandem with in-person visits. Some states, such as Pennsylvania and Rhode Island, seek to maintain or enhance teledentristry policies enacted during the pandemic to increase access to care for low-income children and adults.
In March 2020, Pennsylvania established guidance defining teledentistry as “two-way, real-time interactive communication” between a patient and dental provider. Accordingly, the Pennsylvania Medicaid program dental fee schedule was updated with billing codes D9995 (“teledentistry – synchronous”) and D0140 (“limited oral evaluation – problem focused”). (The D9995 code is not reimbursable, rather it is used to document teledental visits and must be used in conjunction with D0140 to provide services to patients experiencing dental emergencies). This policy lasted for the duration of the state of emergency in Pennsylvania, ending June 10, 2021. Now, officials seek to make permanent these Medicaid policies for preventive teledentistry through developing guidance on:
- virtual supervision of fluoride varnish application,
- tobacco cessation counseling,
- oral hygiene instructions and nutritional counseling,
- limited problem-focused evaluations,
- integration of different settings of care delivery, and
- care coordination for follow up to in-person visits as needed.
Rhode Island is in the process of establishing Medicaid guidance for teledentistry to expand dental services, particularly for children. At the beginning of the COVID-19 pandemic, the Rhode Island Department of Health released guidance allowing providers to bill telehealth services to Medicaid. This allowed dental providers to bill for a care coordination phone call (D9992) and schedule emergency video consultations with patients (D9310). This guidance expired on July 6, 2021, but the Rhode Island legislature recently passed an update to the Telemedicine Coverage Act, which expands telemedicine coverage requirements for Medicaid and private insurers, requires reimbursement rates for telemedicine services to match in-person rates, and ensures that dentists providing teledentistry services be held to the same standards of care that would apply in an in-person setting. Work to communicate reimbursable services to dental providers is in progress.
As states identify approaches to expand the use of teledentistry, many are creating pathways for patients and their caregivers to administer certain preventive procedures under virtual supervision from dental practitioners. As part of a pilot project, Nevada allows parents to apply fluoride varnish for their children under virtual supervision from a licensed dental provider. The Nevada Board of Dental Examiners approved virtual provision of fluoride varnish for individuals under the age of 21 in October 2020. A forthcoming fact sheet will provide more information on Nevada’s fluoride varnish program.
School-linked and School-based Programs
States also are considering how to leverage schools to fill dental care gaps among children. School-based dental sealant programs (SBSPs) provide critical primary and preventive dental care and disproportionately serve low-income students and those living in rural areas. However, according to a 2015 survey, 39 states and the District of Columbia do not have sealant programs in most of their high need schools, and only 5 states have sealant programs in at least 75 percent of high need schools. The Centers for Disease Control and Prevention (CDC) published considerations for SBSPs during the COVID-19 pandemic that includes information on restarting SBSPs. Still, state leaders cited concerns that reestablishing school-based programs will be challenging due to safety concerns, changing guidance, and workforce shortages, and they are searching for other strategies to increase access to dental care for students from low-income households.
To encourage children to visit dental providers in advance of the 2021-2022 school year, Smile, California, the California Medi-Cal Dental Program’s campaign, is partnering with the Office of Oral Health and Local Oral Health Programs to carry out a Back Tooth School Activation. Campaign partners can access Back Tooth School resources on the Oral Health and School Readiness website. Additionally, although the pandemic has limited students’ ability to receive oral care at school, California is pursuing strategies to screen children at school and refer them to dental providers using an electronic referral system. California’s Dental Transformation Initiative created a pilot program to improve dental health for Medicaid-eligible children. More LA Smiles, run through UCLA, is the largest of these pilot projects and created the LA Dental Registry and Referral System (LADRRS) to connect medical providers in clinical settings with dental providers. To implement a school-linked program, a platform like LADRRS can be modified to include referrals from schools. This system will enable state leaders to target low-income schools and gather data on students’ health.
During the roundtable, state leaders shared concerns about the increased challenges school nurses face as a result of the COVID-19 pandemic. The Colorado Department of Public Health and Environment (CDPHE) collaborated with its Department of Education to train over two-thirds of the state’s school nurses to distribute and respond to home screening tools to identify students with urgent oral health needs. Schools give parents or caregivers the option to fill out an oral health screening form, translated into several languages so that school nurses can address care needs or refer students to dental providers.
Federal Funding Opportunities
States can leverage new and existing federal funding opportunities in the wake of COVID-19 to improve oral health access. The American Rescue Plan Act (ARPA) provides significant funding to states and localities to assist in COVID-19 recovery. The Act includes $8.5 billion for a provider relief fund targeted for rural Medicare and Medicaid providers. There are also $500 million in emergency grants for rural health to cover costs associated with increased telehealth capabilities and lost revenue from COVID-19.
ARPA also includes funding for health centers through the Health Resources and Services Administration Health Center Program that serve an important role in the dental safety net. The law allocates $7.6 billion to the Department of Health and Human Services for health centers and includes allowable funding uses with implications for oral health.
For example, four health centers in Rhode Island will use a portion of these funds to pay for community health workers’ engagement in oral health and case management.
Conclusion
Moving forward, states can involve oral health policymakers in planning discussions for allocating newly available federal dollars. As states engage in health transformation efforts, oral health stakeholders can assist states in considering how to integrate dental and medical care to address overall health by leveraging technology, schools and federal resources.
Acknowledgement: The authors thank state officials from California, Rhode Island, Colorado, Pennsylvania, Minnesota, and North Carolina who reviewed a draft of this publication. Additionally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number U2MOA394670100, National Organizations of State and Local Officials. This information, content, or conclusions are those of the authors 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. 
