COVID-19 – Page 7 – The National Academy for State Health Policy

State Plans for Vaccinating their Populations against COVID-19

April 19, 2021/in COVID-19 State Action Center, Policy Charts, Featured News Home, Maps COVID-19, Health Equity, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health, Vaccines /by Rebecca Cooper, Ariella Levisohn and Jill Rosenthal

Spotlight on Home- and Community-Based Services: New Federal Opportunities?

April 5, 2021/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Medicaid Managed Care, Population Health, Relief and Recovery, Social Determinants of Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center, Workforce Capacity /by Kitty Purington

Older adults, people with disabilities, and their family caregivers have been hard hit by COVID 19. As states reel from the pandemic’s human and fiscal toll, policymakers are increasingly looking to home- and community-based services (HCBS) to address the pressing need for alternatives to nursing home care and supporting family caregivers who can help loved ones age in place.

Recent actions signal that the importance of HCBS is gaining traction at the federal level, and may receive significant attention in the coming months:

The American Rescue Act, passed last month, includes a one-year, 10-point boost in Federal Medical Assistance Percentage (FMAP) for HCBS delivered between April, 2021 and March, 2022. The funding must supplement – not supplant – current state expenditures, and can be used for an expansive list of HCBS. These include Medicaid waiver services, but also case management and rehabilitative services, which are often used to support people with serious mental illness. The Centers for Medicare & Medicaid Services recently held a “listening session” to gather input for guidance that will be issued in the near future.
The American Jobs Act, released by the White House on March 31, 2021, has been touted by the Biden Administration as an historic opportunity to rebuild America’s infrastructure. Interestingly, a full quarter of the total $1.2 billion proposed expenditure would go to “expanding access to quality, affordable home- or community-based care for aging relatives and people with disabilities.” The plan targets expansion of Medicaid HCBS and would improve wages and conditions for the nation’s direct care workforce, a majority of whom are women of color.
Also last month, a group of members of Congress – Rep. Debbie Dingell (D-MI), Sen. Maggie Hassan (D-NH), Sen. Bob Casey (D-PA), and Sen. Sherrod Brown (D-OH) – sought input on the HCBS Act of 2021, draft legislation that would make HCBS a mandatory benefit in state Medicaid plans and expand the kinds of services offered, among other changes.

In the short term, states will need to act quickly to develop time-limited strategies to take advantage of the Federal Medical Assistance Percentage (FMAP) enhancement offered by the American Rescue Plan, and be prepared for other funding and policy opportunities as they emerge. States may choose to add enrollees to their existing HCBS programs, expand access by enhancing direct care workforce pay, focus on services to support family caregivers, and/or build on existing programs.

Explore the National Academy for State Health Policy’s (NASHP) State PACE Action Network for a new technical assistance opportunity for states to enhance or expand this home- and community-based services model. NASHP will continue to track these issues, and provide updates on state and federal initiatives that reflect the growing importance of HCBS.

State Approaches to Improve Comprehensive School Mental Health Systems

March 29, 2021/in COVID-19 State Action Center Blogs, Featured News Home Back to School, Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, COVID-19, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Population Health, Relief and Recovery, Social Determinants of Health /by Olivia Randi

The COVID-19 pandemic has negatively impacted the mental health of many children and adolescents and reduced students’ access to comprehensive school mental health systems (CSMHS) as schools shifted to remote learning.

In recent years, states have implemented policies that have successfully expanded access to CSMHS. Lessons learned from these initiatives can help address students’ growing mental health needs and may help reduce states’ health care costs by decreasing mental health-related emergency department visits, which have escalated during the pandemic.

Background

The availability of a comprehensive behavioral health system is critical to a child’s health and well-being. Nearly 17 percent of children and adolescents have a mental health condition, yet almost half of these children do not receive needed treatment. This is more pronounced among children and youth who are Black, Latinx, and come from other racial and ethnic minority groups, which disproportionately face barriers to accessing quality mental health care. These disparities have been amplified by the COVID-19 pandemic. A lack of regular, accessible mental health programs, services, and supports may lead to greater use of emergency departments, which are costlier and often lack appropriate policies to serve children with mental health needs, such as how to transition children and adolescents to other services and provide appropriate care coordination.

Schools are a primary source of mental health services for children and have been shown to improve students’ access to mental health programs, services, and supports. This is true for an increasing number of students, as the percentage of adolescents receiving mental health services and supports in educational settings has grown from 12 percent in 2011 to 15 percent in 2019.

A CSMHS approach is a best practice identified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS). Schools can use this approach to support:

Prevention of mental health needs among all students;
Early identification of students and intervention for those who are at risk; and
Services and treatment for those who have mental health needs.

A CSMHS also supports adherence to treatment, decreased stigma, and improved educational attainment. Implementing and expanding a CSMHS may also help to reduce racial and ethnic disparities in school responses to students’ behavior by encouraging mental health services over punishment. Children and youth with mental health needs who are Black and Latinx are more likely to receive punishment instead of mental health care services in comparison to White children.

A CSMHS is one component of a system of care for children and youth with special health care needs (CYSHCN) and behavioral health needs, and can be considered within a broader framework of policies to support mental health of children and adults.

Federal Policy

There are a variety of federal initiatives that support state efforts to develop and expand these critical school programs, including:

The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) provides funding at state and local levels to promote health and well-being through schools, including programs and services to support students’ mental health;
SAMHSA’s Project Advancing Wellness and Resilience in Education (AWARE) provides funding to state education agencies to partner with state mental health agencies to increase awareness of mental health in schools, provide training to school staff, and connect students with behavioral health needs to services; and
The School-Based Mental Health Services Grant Program, authorized by the 2020 Department of Education budget, provides $10 million to six states to increase the number of mental health service providers in schools.

The Biden Administration has underscored the importance of behavioral health services for students by setting a goal to double the number of mental health professionals in schools. The day after his inauguration, President Biden issued an executive order stating that the federal government will support states in promoting mental health and social-well-being in schools, and the American Rescue Plan Act of 2021 that was signed into law in March 2021 allocates more than $120 billion in grants to states through the Elementary and Secondary School Emergency Relief Fund. The majority of this funding will be distributed to local education agencies, which could use these subgrants to provide mental health services and supports and to implement interventions that address learning loss while responding to students’ emotional needs, among other purposes.

State Policy Considerations

Schools have adapted to shifting priorities over the past year and continue to implement innovative strategies to meet students’ growing mental health needs. During the pandemic, several states have introduced legislation to support schools in various ways to enhance their mental health programs during and after the pandemic.

Implementing statewide task forces. Schools face a variety of barriers to developing CSMHSs for students, including allocating adequate funding, adhering to data privacy regulations, and identifying and implementing best practices. To support school districts’ diverse needs, states are forming committees to review existing approaches and make recommendations to improve mental health programs. This process may be particularly helpful to identify and address emerging challenges and strategies during and after COVID-19.

In 2017, North Carolina created the Superintendent’s Working Group on Student Health and Well-Being to produce recommendations to support students’ mental health, which were released in a report in May 2018. In October 2020, Illinois introduced legislation that would create a similar mental health task force consisting of mental health providers, school nurses, state General Assembly members, school board members, principals, parents, and students to produce recommendations in 2021.

Developing mental health policies in schools. Clear policies at the state and local level can support comprehensive, consistent, and appropriate approaches to addressing students’ mental health needs in schools. State policies can provide guidance for local school districts regarding expectations and best practices, while allowing flexibility for schools to meet their students’ specific needs while considering the local context.

On June 8, 2020, North Carolina enacted SL 2020-7 S476, which implemented recommendations from the state task force. This law requires the Department of Public Instruction to adopt a statewide, school-based mental health policy, and requires each school to adopt its own policy following task force recommendations.

Supporting universal screening practices. Widespread screening for children’s behavioral health needs is a recommended best practice. While schools have a unique opportunity to screen a high proportion of their students for behavioral health needs, less than 15 percent of schools have implemented a universal screening process. States are supporting schools by issuing recommendations for schools to increase mental health screening among students and guidance for funding for these services.

New Mexico requires in its administrative code that schools screen all students for health and well-being, including behavioral health needs. The state has developed guidance on funding sources for screening services, which may include operational funds, Title I and Title III funds, and Coordinated Early Intervening Services funding through the Individuals with Disabilities Education Act. In January 2020, New Jersey introduced legislation that would require schools to provide annual depression screening for students in grades seven through twelve.

Expanding the availability of mental health services in schools. Few schools meet the recommended student-to-staff ratios for counselors, psychologists, nurses, and social workers due to a lack of funding and workforce shortages. States are enhancing CSMHSs through policies that provide funding to increase the availability of mental health professionals in schools and support partnerships with community-based behavioral health agencies.

Washington, D.C. has made significant efforts to support the expansion of behavioral health services to all students by earmarking local and federal funding and increasing funding over time for schools to develop partnerships with community-based mental health services. In October 2020, New Jersey introduced legislation that would require all public school districts to have at least one school counselor and to meet a maximum student-to-school counselor ratio of 250 to 1 – the national recommended ratio.

Improving mental health training and education. School staff who are frequently in contact with students are an important resource to support students’ mental health. States are providing guidance and support to train these staff to identify indicators of mental health needs among students and facilitate appropriate referrals. States also advise on school curricula and education that support mental health awareness among students.

North Carolina’s SL 2020-7 S476 requires the state’s mental health policy to include a model mental health training program for school staff that local school districts must adopt. All school staff who work with students in grades K-12 must be trained in youth mental health, suicide prevention, and other mental health-related topics. Pennsylvania introduced similar legislation in September 2020 that requires schools to train school staff in identifying signs of depression and referring students and their families to mental health services.

Conclusion

Comprehensive school mental health systems are an important component of systems of care for CYSHCN and behavioral health needs. The National Standards for Systems of Care for CYSHCN, which were developed by a national work group of state and national health policy leaders, is a valuable resource that states can use to guide improvements to systems of care for CYSHCN, including considerations for mental health systems. States can implement systems based on the following standards to improve care for CYSHCN during and after COVID-19, including:

Improve mental health care access, especially for marginalized communities;
Increase the use of medical homes serving individuals with chronic and complex conditions;
Improve coordination of care across behavioral health, social and health systems; and
Improve access to CSMHS.

Schools have played an important role in supporting students’ mental health, but often face challenges in implementing CSMHS. Mental health needs among children and adolescents have been rising for several years, and this trend has been exacerbated by the pandemic. One way that states can address this is through policies that strengthen CSMHS to support students during and after the pandemic. The National Academy for State Health Policy will continue to track state policies that support CSMHSs during and after the COVID-19 pandemic.

Medicaid Agencies Cultivate Partnerships and Deploy Data to Bolster COVID-19 Vaccination Efforts

March 29, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Health IT/Data, Medicaid Managed Care, Population Health, Program Design, Quality and Measurement, Social Determinants of Health, Special Populations and Services, Vaccines /by Christina Cousart

COVID-19 vaccine distribution has accelerated across states as the Biden Administration updates its vaccine goal to 200 million doses by April 23, 2021 and many states are opening eligibility to all adults by early April. The National Academy for State Health Policy (NASHP) recently spoke with several state Medicaid officials to learn more about how their agencies – and specifically their Medicaid managed care organizations (MCOs) – are leveraging partnerships and data to advance their vaccination efforts.

Leadership and communication across state agencies are enabling optimal coordination.

States’ COVID-19 vaccination efforts are primary led by their departments of health (DOHs), but nearly every other state agency plays a role in helping to raise awareness with the constituencies they serve or by aiding with vaccine logistics and administration – often both. To reduce confusion, agencies must work in lockstep, agreeing on policies while using similar messaging and data sources to promote accurate information about the vaccine. In the case of Medicaid, state officials work not only to convey vaccine updates from their state DOH to Medicaid enrollees, but also to the health plans and providers they work with. Medicaid agencies have revised call center scripts, website content, and other resources so they are in line with the latest language put forth by their DOHs.

View state-by-state vaccination eligibility plans at: State Plans for Vaccinating their Populations against COVID-19.

To improve coordination, Medicaid agency officials participate in, and sometimes lead, weekly meetings with state and county officials to update them about the latest vaccine progress. They have also worked with state and county officials to identify and share data about Medicaid enrollees to enable improved targeting of high-risk, and/or priority populations for outreach by state and local authorities. Medicaid agencies have also shared data about provider networks to aid vaccine administration efforts. Specifically, data has been used to recruit providers who are already actively engaged in serving certain populations as part of direct vaccination efforts, including as vaccine administrators at mobile vaccination sites.

Empowering Medicaid health plans encourages innovative vaccination promotion strategies.

Along with collaborating with state and local agencies, Medicaid agencies have also cultivated stronger relationships with their MCOs and other participating health plans to promote vaccinations. Several states’ officials report meeting with their health plans on a biweekly or weekly basis to share the latest updates on vaccination policy, as well as to strategize about best practices to encourage vaccination. United by a mutual goal of encouraging members toward health and away from catastrophic illness, the vaccination effort provides a unique opportunity for Medicaid to work in partnership with its health plans and encourages innovative approaches to improve vaccination rates. Some innovative strategies include:

Distributing educational material about how to schedule appointments and appointment reminders;
Enabling plans and plan representatives to schedule appointments on behalf of enrollees;
Active post-vaccination outreach to assess vaccine side effects;
Communication to family members and care takers about vaccine eligibility and access; and
Development of training modules for care managers to address vaccine hesitancy.

Several officials especially noted the challenge of ensuring transportation to and from vaccination sites. To mitigate these issues, states have employed various methods of moderating this barrier – from providing access to free transportation services to mandating that health plans cover transportation to and from vaccination sites. One state had a policy to reimburse enrollees for miles traveled, while another worked with carriers to set a rate for transit services that included a “wait time” between arrival at and departure from the vaccination site.

Access to state data is critical to health plan participation in vaccination efforts.

Beyond sharing strategies to encourage outreach and access to vaccination sites, Medicaid agencies have played a key role in sharing critical data about Medicaid enrollees directly with MCOs or other participating carriers.

Medicaid agencies have unique access to state data sources, including Medicaid enrollment and claims data and vaccination data from public health data repositories, which is otherwise not available to private companies or other agencies. Access to this data not only positions a state Medicaid agency to take an active role in identifying enrollees to target for vaccination outreach, but it also enables it to perform analytics across data sources. For example, some states are cross-walking vaccine registry data with Medicaid data to identify Medicaid recipients who have scheduled vaccination appointments or who have been vaccinated. This ability to crosswalk data from vaccine registries is especially important, as many vaccines are scheduled and administered without an insurance claim, leaving health plans without any information about the vaccination status of their enrollees. However, armed with Medicaid data and analytics, health plans are able to conduct direct follow-up with their members. In several cases, states report active participation from health plans that are using data to encourage vaccination, including among high-risk individuals. Others go further and connect enrollees with case managers who may be able to assist with arranging transit to and from appointments or scheduling follow-ups for the second vaccine dose.

Capacity to conduct complex analytics may be limited based on states systems’ ability to extract and share data across agencies, and outdated claims processing systems may affect the timeliness of available data. Meanwhile, vaccination databases are in the midst of being brought to scale in tandem with escalating vaccination efforts, and data may not yet be fully accessible or up to date in state systems. State agencies are rapidly working to improve data capacity, including efforts to enable direct connections between carriers and providers to data sources or analytic information. One state also reported efforts to access data from border states, to ensure it had updated vaccination information even for those that may get vaccinated outside of the state.

States have and continue to rapidly adapt in response to the ever-evolving pandemic. As vaccine capacity increases, they will continue to build on their growing resources and infrastructure to address changing needs and circumstances. As they do, NASHP will report on the development of new policies and promising practices from those at the forefront of addressing the COVID-19 crisis.

States Address Racial and Ethnic Disparities in their COVID-19 Responses and Beyond

March 22, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Equity, Health Equity, Housing and Health, Population Health, Relief and Recovery, Social Determinants of Health /by Allie Atkeson and Rebecca Cooper

More than a year into the pandemic, COVID-19 is proving to be a complicated syndemic with political, economic, and social factors influencing who is most at risk of infection and death. With communities impacted by structural racism facing higher COVID-19 infection and mortality rates, state responses and recovery plans are focusing on equity.

The latest update to the National Academy for State Health Policy’s (NASHP) interactive map and chart, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, highlights the cross-sector actions states are taking to reduce COVID-19 inequities. Many are:

Developing strategies to create resilient public health systems capable of weathering future challenges; and
Developing longitudinal, agency-level changes, such as instituting racial equity impact assessments to determine the impact of state policies on various racial and ethnic groups.

Discover how states are reporting race and ethnicity in their COVID-19 cases and how they’re addressing equity here.

States Emphasize Equity in COVID-19 Response

Washington, DC has prioritized equity in its coronavirus response and vaccine distribution strategies. The Reopen DC Taskforce designated a subcommittee to focus on vulnerable populations to address the inequities of the pandemic including the disproportionate impact on African American individuals in case counts and deaths. The subcommittee has assembled several recommendations addressing social and economic determinants of health for Mayor Muriel Bowser to consider as she works to create an equitable reopening plan based on science and tailored to community needs. The District is focusing on prevention, health outcomes, and access to resources by collecting and publishing race/ethnicity data to guide their initiative to reopen the District. The District is also exploring philanthropic partnerships to help provide health and economic support to communities of color. The committee’s recommendations focus on:

Council Office of Racial Equity’s (CORE) Framework for Equity:

Focus on racial equity;
Put people first;
Invest in community infrastructure;
Build an equitable economy; and
Protect and expand community voices and power.

Employment and income;
Education;
Food environment;
Health and medical care;
Housing;
Transportation;
Outdoor environment; and
Community safety.

The committee recommends sustaining investments in the expansion of supportive and affordable housing for domestic violence victims and incarcerated individuals re-entering their communities, as well as non-congregate housing for people experiencing homelessness.

The committee also recommends incentivizing employers who accommodate extended work-from-home requests from employees and working with pharmacies and other medical corporations to prevent treatment shortages in underserved areas.

The DC Council has also passed legislation to create the Council Office of Racial Equity (CORE). CORE recently released a report in March examining racial equity in the District’s vaccination rates and practices, and proposing best practices to ensure the District can ensure a racially equitable process moving forward. For example, to ensure equitable vaccine distribution, the District prioritizes doses for individuals living in high-need zip codes and has restricted registration on certain days to allow only those individuals to sign up on the vaccine portal or call the vaccine hotline. CORE is currently working on another report that focuses on a racially equitable economic recovery.

In Illinois, the Department of Public Health established a COVID-19 Health Equity Task Force to work across the department and with other relevant state and local entities to assess health concerns of minority communities and create and maintain culturally sensitive programs. The task force launched a COVID-19 text messaging system that includes a Spanish-speaking option. The department also supported the City of Chicago, in partnership with the city’s chief equity officer, to create the Racial Equity Rapid Response Team (RERRT) to address the disproportionate effects of the pandemic on communities of color. The city experienced a significant improvement in vaccine administration to communities of color by February 2021 as a result of RERRT’s oversight and involvement.

Georgia’s Department of Public Health created a COVID-19 Health Equity Council to ensure equity in COVID-19 vaccination education and distribution efforts in communities most affected by COVID-19. Members of the council represent community-based organizations, news stations, chambers of commerce, and universities. The council will work with Georgia’s 18 public health districts to address COVID-19 concerns.

State Actions to Address Equity Beyond the Pandemic

States are making financial and cross-agency leadership commitments to ensure equity is the focus of their work moving forward. Washington, DC, Illinois, Indiana, and Washington State have recently hired or are in the process of hiring cabinet-level positions to oversee inter-agency diversity, equity, and inclusion (DEI) initiatives. States are also implementing cross-sector equity plans and making significant investments in identified program and policy areas.

Washington’s state legislature passed HB 1783 in 2020 to create the Office of Equity. Lawmakers explained, “the legislature finds that a more inclusive Washington is possible if agencies identify and implement effective strategies to eliminate systemic inequities.” In February 2021, Gov. Jay Inslee named a director of the program to be in office by March 8. The office will be staffed by eight people and is tasked to develop and implement a five-year equity plan for the state. Staff will work with other state agencies to help create and implement DEI plans.

In his $365 million equity policy package, Gov. Inslee earmarked $2.5 million from the state’s general fund for the office. Other state equity priorities include:

$10 million for the Washington COVID-19 Immigrant Relief Fund;

Funding for the Office of Minority and Women’s Business Enterprises to launch the Washington State Toolkit for Equity in Public Spending to increase the number of minority and women contractors;
Funding for the Department of Financial Institutions to address racial wealth inequities by working with financial institutions, federal, state, and local governments, and community partners;
$79 million to support residential broadband connection for families and $6 million for a Digital Navigator Program that enables navigators to provide one-on-one support for students, English language learners, older adults, and individuals searching for work; and
$8.4 million for students who experienced foster care or homelessness, including $3 million for pre-apprenticeship training.

In Florida, bills introduced in the House of Representatives and State Senate (HB 183 and SB 404) require each county health department to designate a minority health liaison. The liaison will collaborate with the state Office of Minority Health and Health Equity on implementation of programs, policies, and practices. Examples of these activities include:

Data analysis for disparities in health status, health care quality, and access to care for racial and ethnic minority populations;

Demonstration projects to increase health equity;

Community health workers working to improve cultural competency and individual and community self-sufficiency;

Analysis of a community’s risk for involvement in the adult and juvenile legal system and foster care system, or risk of homelessness. Available support programs and diversion programs addressing these areas will also be examined; and

Developing and executing programming for individuals with limited English proficiency to help them better access health care services.

Racial equity impact assessments are another strategy to address equity beyond the pandemic. These assessments help determine the impact of a policy or budget item on racial and ethnic groups. Seven states (CO, CT, FL, IA, MD, NJ, and OR) require racial impact statements. The following states recently took action to establish racial impact assessments:

Maine’s legislature passed LD 2, a bill that requires the inclusion of racial impact statements in the legislative process. The bill allows legislative committees to request state agencies to provide analysis of the impact of pending legislation on historically disadvantaged racial populations.
The Virginia General Assembly passed HB 1990, a bill that allows the chairs of the House Committee for Courts of Justice and Senate Committee on the Judiciary to request racial and impact statements from the Joint Legislative Audit Review Commission. Committee chairs may not request more than three racial and ethnic impact statements during a single session.
The Washington, DC Council passed L23-0181, the Racial Equity Achieves Results (REACH) Act. Among other activities to ensure racial equity in the District, the legislation creates a racial impact assessment requirement for council legislation. The District’s Council Office of Racial Equity (CORE) is charged with evaluating legislation prior to committee markup for its potential impact on racial equity.

States are taking important steps to immediately address the impact of COVID-19 on racial and ethnicity disparities and incorporating health equity approaches into their systems moving forward. In their 2021 state of the state addresses, 21 governors highlighted strategies to address racial and ethnic disparities. Several governors specifically discussed racism and racial injustices, citing how communities of color were disproportionately impacted by COVID-19 and articulating their commitment to improvement. The recent passage of the American Rescue Plan will provide significant financial support to states for their recovery efforts. States have the opportunity to center equity in their dispersal of funds and address the health, social, and economic impact of COVID-19.

To read more about state initiatives to address health equity, explore NASHP’s toolkit, Resources for States to Address Health Equity and Disparities.

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.

Manufacturers to Pay Higher Rebates for Drugs with Large Price Increases under the American Rescue Plan

March 22, 2021/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Administrative Actions, Legal Resources, Prescription Drug Pricing, Relief and Recovery, State Rx Legislative Action /by Johanna Butler

In addition to providing critical funding for state COVID-19 response efforts, the American Rescue Plan requires drug manufacturers to pay more in Medicaid rebates for drugs with large price increases. This change, effective in 2024, has the potential to generate significant federal and state savings.

Under the Medicaid Drug Rebate Program (MDRP), manufacturers are required to provide certain rebates to state Medicaid programs in order to have their drugs covered by Medicaid. States and the federal government share these rebates based on the federal medical assistance percentages (FMAP), which is the share of state Medicaid spending paid for by the federal government. The rebate amount a manufacturer provides to states is determined by two federal rebate requirements:

Without the rebate cap in place, manufacturers face a new pricing landscape that requires them to pay larger Medicaid rebates if they significantly increase a drug’s price.

A basic rebate: This rebate amount is based on a percentage of the average manufacturer price (AMP) – 23.1 percent for most brand-name drugs and 13 percent for generic drugs, and
An inflationary rebate: An additional inflationary rebate is applied if the increase in a drug’s AMP exceeds inflation, defined by the urban consumer price index.

Under the current formula, the total rebate amount a state can receive (when the basic plus inflationary rebates are applied) cannot exceed 100 percent of a drug’s AMP. A drug manufacturer typically triggers this cap only if it increases a drug’s price substantially over time and therefore must provide such a large inflationary rebate that the rebates equal the drug’s price. Once the cap is reached, a manufacturer has little incentive to moderate drug price increases as they can charge a higher price to other private plans without paying larger rebates to Medicaid programs.

The American Rescue Plan eliminates the rebate cap, creating incentives for manufacturers to limit price increases and enabling state Medicaid agencies to collect more in rebates when large price increases occur. Without the rebate cap in place, manufacturers face a new pricing landscape that requires them to pay larger Medicaid rebates if they significantly increase a drug’s price.

This change reflects a June 2019 Medicaid and Children’s Health Insurance Program Payment and Access Commission (MACPAC) recommendation. In its recommendation, MACPAC highlighted that the change would result in higher Medicaid rebates and put downward pressure on manufacturer price increases. At the request of MACPAC, the Congressional Budget Office estimated potential savings from this change would be $15 to $20 billion in federal savings over 10 years. States would receive the non-federal share of these savings to their Medicaid programs. MACPAC, however, did caution that this change would only address drugs with large price increases – not drugs with high-launch prices.

MACPAC is currently considering an additional recommendation to change the MDRP related to rebates on drugs that receive accelerated approvals. An accelerated approval is a Food and Drug Administration (FDA) pathway that allows for quicker approval of drugs that treat serious or life-threatening conditions and fill an unmet medical need. MACPAC is considering a proposal to increase rebates required for drugs that receive an accelerated approval until the manufacturer completes the required post-market clinical trials.

The goal of the MDRP change would be to increase rebates on these drugs while there is limited clinical evidence of their effectiveness and to incentivize manufacturers to complete the post-market trials that are often delayed or take a number of years to complete.

Guidance from the Centers for Medicare & Medicaid Services in 2018 made it clear that state Medicaid programs are required to cover drugs approved through the accelerated approval pathway, despite the fact that these drugs often having high prices and unclear evidence of clinical benefit. Recently, indications for two drugs that received accelerated approvals – the cancer drugs Tecentriq and Imfizi – were withdrawn after follow-up trials showed the drugs did not improve overall survival.

MACPAC will vote on the recommendation to increase rebates for drugs with accelerated approvals at its April meeting. The National Academy for State Health Policy will follow its actions.

The 2021 American Rescue Plan Act’s Major Health Care Provisions

March 15, 2021/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Consumer Affordability, COVID-19, Eligibility and Enrollment, Equity, Health Coverage and Access, Health Equity, Health System Costs, Housing and Health, Medicaid Expansion, Population Health, Relief and Recovery, Social Determinants of Health, State Insurance Marketplaces, Workforce Capacity Recovery and Relief /by Christina Cousart

State Policy Center for Opioid Use Disorder Treatment and Access

March 9, 2021/in Policy Featured News Home, NASHP News, Toolkits Behavioral/Mental Health and SUD, Chronic and Complex Populations, COVID-19, Featured Policy Home, Health Equity, Physical and Behavioral Health Integration, Population Health /by Jodi Manz and Kitty Purington

Johnson & Johnson COVID-19 Vaccine Helps States Boost Supply, But Messaging Remains Critical

March 8, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health, Vaccines /by Ariella Levisohn

The US Food and Drug Administration’s (FDA) recent approval of the one-dose Johnson & Johnson (J&J) vaccine, which is easier to store and transport than others and reportedly causes fewer side effects, offers opportunities for states to improve vaccination outreach.

At a time when supply remains one of the largest barriers to vaccine administration, the new J&J vaccine helps boosts supply and allows more people to be vaccinated. However, efforts to distribute the newest vaccine have been complicated by mixed messaging around its efficacy. States, with federal guidance, are working to emphasize the benefits of the J&J vaccine and the importance of getting vaccinated as soon as any vaccine is available.

Background

In clinical trials, the J&J vaccine had a 72 percent efficacy overall in the United States, with an 85 percent efficacy against severe COVID-19 infection. While there is some public concern that the J&J vaccine has a lower efficacy than Pfizer and Moderna’s, experts are stressing two facts:

The (J&J) vaccine has a high efficacy against severe disease and is just as effective at preventing hospitalization and mortality as the older vaccines. Those who do get COVID-19 after J&J vaccination are likely to only experience only mild symptoms.
Unlike the Moderna and Pfizer vaccines approved in December, J&J was tested in Brazil and South Africa in the presence of the new 1.351 variant. It proved to be highly effective at preventing infection and severe disease from these COVID-19 variants.

J&J Vaccine Advantages

In addition to its success against virus variants, the J&J vaccine has a number of different characteristics that make it easier to transport, store, and administer than the Moderna and Pfizer vaccines.

First and foremost, the vaccine requires one dose rather than two. State officials have shared that scheduling second doses, reminding patients to come in for their second dose, and following up when individuals miss their appointments have been significant challenges in their vaccine rollout. The one-dose J&J vaccine eliminates this issue.

Additionally, the J&J dose is easier to store and can be kept in a regular refrigerator for up to three months. This makes it possible that more and different types of health care providers, such as those working in rural health centers or with communities that have limited access to health care, can keep the vaccine in their facilities so their patients can receive the COVID-19 vaccine from providers whom they view as trusted sources.

Many J&J recipients also report fewer side effects from the vaccine, making the vaccine ideal for individuals who cannot afford to miss a day of work because of severe side effects, or who might not be connected to a health care professional who can help treat symptoms if needed.

Importance of Messaging

Throughout the pandemic, federal and state governments and public health leaders have struggled to find a balance between managing public expectations and encouraging measures that prevent the spread of COVID-19. The introduction of the J&J vaccine has again highlighted the importance of crafting messages for the public to counter any misinformation about its efficacy.

After concerns began arising about the efficacy of the J&J vaccine, the Centers for Disease Control and Prevention (CDC) recommended that jurisdictions use the following language when promoting the J&J vaccine, “All the available vaccines have been proven effective at preventing serious illness, hospitalization, and death from COVID-19 disease.” The CDC also encourages individuals to get the first vaccine available to them. States are beginning to craft their own messages to reach their residents.

Before opening up new vaccine appointments, the Washington, DC Department of Health sent an email using the CDC’s language to all residents who signed up for vaccine alerts. The email noted that individuals will be able to see which vaccine is being administered at each site before choosing an appointment, but emphasized that all vaccines are effective at preventing “serious illness, hospitalization, and death from COVID-19,” and that residents are “highly encouraged to take the first vaccine available to them.” All appointments were booked within minutes, suggesting that Washington, DC residents were willing to take whichever vaccine was available.

In Iowa, Gov. Kim Reynolds received the J&J vaccine during a news conference to help promote the vaccine and emphasized her trust in the vaccine before her constituents. She also addressed concerns about the J&J vaccine’s efficacy, noting, “This information is misleading, and quite frankly, it’s irresponsible to position any vaccine as a less desirable option when it’s undergone the same rigorous clinical trials to test the safety and efficacy and has received approval by the FDA and the CDC.”

Gov. Jay Inslee of Washington State also issued a statement about the J&J vaccine in a recent interview, where he acknowledged the lower efficacy rates in clinical trials, but also praised the advantages of this vaccine compared to others. “It’s going to save your life, which we think is a pretty high value. It has a downside of slightly lower efficacy to prevent you from getting a headache — but you only have to have one shot instead of two,” he explained.

Federal and state governments are also navigating the tension between the value of setting aside allocations of the J&J vaccine for individuals who face more barriers to getting two doses, and the danger of targeting a vaccine that some constituencies believe is less valuable to more vulnerable and historically marginalized populations.

Conclusion

Supply remains a key concern in state and federal vaccination efforts. However, President Biden’s announcement that the United States will have enough supply to vaccinate the entire adult population by May, in part due to J&J’s partnership with Merck to ramp up manufacturing, creates even more pressure to ensure that public health messaging effectively promotes the benefits of all vaccines equally.

In the meantime, the J&J vaccine arrives as many states are broadening their vaccine eligibility guidelines. According to National Academy for State Health Policy analysis, 35 states are now vaccinating individuals age 65 and older and 43 states are vaccinating teachers and/or childcare providers. During the first week of March, 11 states began vaccinating teachers, and four states expanded eligibility to individuals age 50 and older. This new vaccine can help ensure that newly eligible individuals can be vaccinated promptly, bringing the nation closer to herd immunity.

Acknowledgements: 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 for Vaccinating Individuals Experiencing Homelessness against COVID-19

March 8, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health, Vaccines /by Ariella Levisohn

Individuals experiencing homelessness often face more barriers to obtaining a COVID-19 vaccination than others. As more vaccines become available and supplies increase, new and emerging best practices for vaccinating individuals in homeless shelters may help states more efficiently vaccinate other hard-to-reach or medically vulnerable populations, such as those living in rural areas or congregate settings.

Introduction

The Centers for Disease Control and Prevention (CDC) classifies individuals experiencing homelessness as a high-risk population. Homeless shelters are congregate settings, which can facilitate the rapid spread of COVID-19 infection, and many individuals who are homeless also suffer from other medical conditions that put them at high risk of COVID-19-related complications. While some states group all individuals residing in congregate settings into one vaccination priority category, others specifically identify individuals in homeless shelters as a priority population. As a result, these individuals’ vaccination eligibility differs between states.

According to a recent analysis by the National Academy for State Health Policy (NASHP), 34 states explicitly include residents of homeless shelters as a priority population. A few states, including Wyoming and Washington, DC, explicitly prioritize “individuals experiencing homelessness.” Washington State lists “people experiencing homelessness that access services or live in congregate settings (e.g., shelters, temporary housing)” in its latest vaccine prioritization plan.

Every state has changed its eligibility criteria and prioritization guidelines as the CDC and the Department of Health and Human Services (HHS) have issued new recommendations based on the constantly changing vaccine rollout picture. Some states have identified these individuals in their plans and moved this population up in priority, while others have instead reprioritized other populations. For example, Wyoming recently moved individuals experiencing homelessness up in their prioritization. Arizona elevated individuals with high-risk medical conditions living in shelters as well all adults in congregate settings. Wisconsin added individuals in homeless shelters and in transitional housing to a priority phase of the state plan after previously not prioritizing this population. As of March 1, 2021, 15 states were vaccinating individuals experiencing homelessness.

Challenges

In addition to the general vaccine distribution challenges states are facing – such as limited vaccine supplies, tracking data on doses administered, personnel shortages, and vaccine hesitancy – vaccinating individuals experiencing homelessness has its own difficulties:

Conflicting priorities: On top of concerns about vaccine safety and mistrust of the health care system, many individuals experiencing homelessness are hesitant to receive the vaccine because they see other challenges – such as housing status, food insecurity, and financial instability – as more immediate concerns.
Transportation barriers: Many individuals experiencing homelessness face transportation barriers that prevent them from traveling to mass vaccination clinics.
Tracking second doses: For those who receive the Moderna or Pfizer vaccines, the state must figure out how to track where individuals are to ensure they receive their second dose and are fully immunized. It is particularly challenging for states to track second doses for individuals who are only in a shelter temporarily, or primarily live on the street.
Limited technology: Many people living on the street or in shelters do not have internet access, and therefore cannot sign up for vaccine appointments through state websites.
Connection to health care providers: Individuals experiencing homelessness are less likely to be connected to health care providers or health care systems, making it more difficult to get an appointment or find out when they are eligible.
Vaccine Storage: In order to reach individuals living on the street, providers need to be able to transport doses to encampments and other areas where individuals frequently live. However, the vaccines’ refrigerated storage requirements make bringing doses directly to individuals on the street difficult.

States are working diligently to determine strategies and best practices for vaccinating individuals experiencing homelessness. As supply increases and becomes less of a barrier to vaccine administration, it is critical to address access-related barriers that may prevent some individuals from receiving the vaccine and exacerbate existing health disparities.

State Approaches

As with most decisions related to vaccine distribution, eligibility criteria for priority populations has been left to states. Of the limited states already vaccinating individuals experiencing homelessness, many have turned to private organizations to aid in vaccinating individuals experiencing homelessness. In these cases, the state distributes doses to nonprofit organizations that work to address homelessness or provide health care to the homeless, and these organizations take the lead in organizing clinics and administering doses.

Since early February 2021, the Washington, DC Department of Human Services has partnered with Unity Health Care, the District’s largest network of federally qualified heath centers, to hold vaccination clinics at homeless shelters. Unity Health Care is also trying to vaccinate individuals living on the street when possible through case managers and outreach teams. Washington, DC is eliminating certain barriers to vaccination for individuals experiencing homelessness, including waiving the requirement to provide an ID at appointments, giving individuals waterproof wallets in which to keep their vaccination cards, and providing free transportation to clinics located at some homeless shelters.

In Connecticut, the state and local health departments are coordinating vaccination efforts in congregate facilities – including homeless shelters – affiliated with the state, and partnering with private nonprofits to actually administer the doses. Some hospitals and cities in Connecticut are also using mobile vaccination clinics to reach individuals in congregate settings.

In Massachusetts, the nonprofit Boston Health Care for the Homeless Program (BHCHP) is playing a crucial role in vaccinating individuals experiencing homelessness in the Boston area. BHCHP is leveraging the City of Boston’s Homeless Management Information System (HMIS) – which connects to their electronic health records system Epic – in conjunction with the state’s Immunization Information System (IIS) to track first doses administered and to send out second dose text reminders. Shelter can access these reminders and provide outreach to patients to make sure they get their second doses. BHCHP is also using their grant funding and their own funding to incentivize vaccinations among the populations they serve, including providing gift cards, clothing, and snacks and combatting vaccine hesitancy by training individuals experiencing homelessness to provide peer counseling. To date, the nonprofit reports it has been successful at ensuring individuals return for their second doses. BHCHP also announced plans to start vaccinating individuals living on the street. They hope to use a van to store doses while they drive to areas where individuals on the street often live.

As states try to simultaneously provide information about vaccination clinic locations, recruit and train personnel to administer vaccines, monitor individuals after vaccination, and plan mass clinics, nonprofits are a valuable resource for reaching specific populations. Many private organizations, especially those already working to address homelessness and housing insecurity, have existing relationships with individuals experiencing homelessness and are already trusted service providers. They have been providing outreach to these communities throughout the pandemic and are poised to take on some of the work of vaccinating individuals experiencing homelessness.

Looking Forward

Because demand for the vaccine still exceeds supply, states are challenged to prioritize their populations. States have to make tough decisions that promote health equity, decrease infection rates, promote vaccine efficiency, and prevent deaths. States that have not yet started vaccinating individuals experiencing homelessness can learn from others that are already vaccinating this population so that they can more effectively reach those living in shelters and on the street.

As states – and their partnering nonprofits – pilot strategies like mobile vaccine clinics and offer incentive payments and peer counseling in order to reach individuals experiencing homelessness and encourage vaccinations, these and similar initiatives can inform efforts to vaccinate other hard-to-reach populations.

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