State Employee Health Plans Confront COVID-19
State employee health plans (SEHPs), which provide health coverage for millions of public employees, their dependents, and some retirees, are making rapid changes to address the COVID-19 pandemic. This retooling of insurance plans must meet emerging federal requirements and ensure that coverage meets enrollees’ needs while managing costs and anticipating budget constraints.
During a recent teleconference convened by the National Academy for State Health Policy (NASHP), SEHP administrators shared strategies for implementing new federal mandates and highlighted ways they are making changes to other benefit offerings.
Federal mandates: The Family First Coronavirus Response Act and the Coronavirus Aid, Relief, and Assistance Act (CARES Act) added mandates to SEHP coverage, including:
- Any COVID-19 testing, preventive services, treatment, and vaccine are now covered with no member cost sharing.
- Telehealth benefits are to be made widely available and under a high-deductible health plan, these visits are excluded from deductible provisions.
These provisions are designed to reduce immediate individual cost responsibilities that can be a barrier to accessing these services. However, costs are not eliminated, so each SEHP must cover them. During their teleconference, administrators noted that language in the CARES Act requires health plans to reimburse diagnostic testing at the negotiated rate for “items and services,” which is charged by in-network providers. However, out-of-network providers should be reimbursed for the “cash price as listed on public internet websites,” which presents a potentially costly challenge.
SEHP administrators are concerned about these out-of-network claims because they could be expensive, unpredictable, and subject to change throughout the course of the pandemic. NASHP will monitor the impact this CARES Act provision has on SEHPs.
Benefit design: Plan administrators have worked with their governing structures, which in some states include trustees and boards, to make changes that help ensure that enrollees have access to needed care. North Carolina’s SEHP administrator made changes to prior authorization requirements, in addition to other changes. SEHPs across the country also adopted pharmacy refill flexibilities that include paying for refills sooner or covering a greater number of doses, etc. and lifted member non-payment penalties during the COVID-19 emergency.
Plan eligibility: Eligibility for coverage becomes an issue as public entities add temporary staff or reduce employee hours. Washington State is not only extending enrollment paperwork deadlines for new hires, but also implementing a new eligibility policy for targeted new state employees. Effective April 1, 2020, anyone hired or rehired in a specific position type and who works a minimum of eight hours is eligible for benefits with the full employer contribution for benefits. Washington defined the position types as:
- First responders (firefighters, police, EMTs, public safety personnel, etc.);
- Health care professionals (physicians, nurses, pharmacists, behavioral health specialists, etc.);
- Any medical facility position (e.g., health care professionals, lab technicians, administrative staff, sanitation workers, etc.);
- Public health officials; and
- Any COVID-19 research position.
Washington is also extending the maximum number of months for Continuation of Health Coverage (COBRA) and other self-pay coverage options until two months after the state of emergency is lifted.
Monitoring: While SEHP leaders strive to ensure enrollees have access to needed providers without delay, they are stewards of public funds and must be vigilant and aware of opportunists who may take advantage of this crisis, so they must maintain fraud prevention policies. As signature requirements for medical supplies and prescription drugs are eased to ensure access, New Jersey is exploring alternative forms of verification. For example, New Jersey’s SEHP administrator encouraged the plan’s third-party administrators to conduct follow-up phone calls or track data analytics to ensure enrollees received home deliveries of prescriptions or medical supplies.
Telehealth: Many plans are extending telehealth services beyond the requirements mandated by the CARES Act. Specifically, plans are now including mental health and physical therapy care through remote care options, as well as considering maintaining these benefit plan offerings after the pandemic, such as critical substance use services.
These changes and others that are being made as needed to meet the demands for flexibility and new services to respond to the pandemic could be costly. However, the financial impact to these plans is still evolving, and there are many unknowns. But what administrators acknowledged is that initial costs will increase for COVID-19-related hospitalizations, testing, and preventive services. Moving forward, it is anticipated that plan costs will continue to increase as a result of COVID-19 treatments and related vaccines. While COVID-19 costs increase, there has been a corresponding decrease in elective procedures, but administrators don’t know the financial impact of these delayed treatments, elective procedures, and foregone care. SEHPs have funding reserves to cover their immediate cost increases but may need to raise premiums and/or enrollee cost sharing in the future.
SEHP administrators also acknowledged the significant impact of the economic crisis and its immediate impact on reducing state revenues, which will have a serious impact on state budgets that finance SEHPs. One official noted there has already been an $11 million “withhold” from her SEHP budget in response to the dramatic loss of state revenue. NASHP and SEHP leaders will work together to analyze these impacts and will share analytic models to assist SEHPs in projecting impacts to their plan reserves, contributions, and premiums.
Meanwhile, the CARES Act’s Title VI Relief Fund authorizes the US Treasury Department to issue $150 billion in payments to states, tribal governments, and units of local government. The receipt of funds must be used for necessary expenditures due to the COVID-19 public health emergency that were not accounted for in the most recent state budgets and are incurred between March 1 and Dec. 20, 2020. SEHPs may consider working with their respective leaders and executive branch members to determine qualifications for receiving relief funds for their plans.
This new NASHP chart details the amounts and required oversight of COVID-19 federal funds allocated to hospitals, providers, and states by the Families First Act, CARES Act, and HR 266.
States’ Recent 1115 Waiver Applications Include Provisions to Support Children during the Pandemic
More than a dozen states have recently submitted 1115 waiver applications that have the potential to safeguard access to care and increase support for children during the COVID-19 pandemic.
If approved, these 1115 waivers would be retroactively to March 1, 2020, and expire “no later than 60 days after the end of the public health emergency.” The Centers for Medicare & Medicaid Services (CMS) created an 1115 waiver template for states to use when requesting authority to address the impact of COVID-19 on their Medicaid programs. The National Academy for State Health Policy (NASHP) April 6, 2020, blog, State Medicaid Strategies to Maintain Access to Care for Children with Special Health Care Needs during the Pandemic, outlines steps states are taking to support children with special health care needs using 1135 and 1915(c) Appendix K emergency waiver authorities.
Of the COVID-related 1115 waiver applications reviewed by NASHP, several contain provisions related to children. The 1115 waiver provisions listed below represent a selection of key strategies for serving children during the COVID-19 pandemic that other states may want to consider for their Medicaid programs, including payments to foster caregivers, reimbursement of family caregivers, and telephonic and virtual care coordination services.
Payments to foster caregivers: Children in foster care are more likely to experience physical and mental health challenges compared to children in the general population. During the COVID-19 pandemic, children in foster care may not be able to access their typical support services through schools and specialty physical and mental health providers. Arkansas, for example, is acknowledging the importance of providing stability and support to these vulnerable children by requesting authority through a 1115 waiver, to provide an additional monthly payment to all foster caregivers (“licensed foster parents, relative caregivers, and fictive kin”) for providing at-home care for children in their care. These monthly payments would be designed to “prevent negative impacts to physical and mental health during emergency period.”
Reimbursement for family caregivers: Both Georgia and New Hampshire have included provisions in their 1115 COVID-19 waiver requests asking for Medicaid reimbursement of family caregivers for caring for youth with special health care needs. Georgia’s 1115 waiver request would add a family caregiver service to its Georgia Pediatric Program in the event that licensed professional nurses (LPNs) are not available to provide the child’s needed services. New Hampshire’s 1115 waiver request asks to waive CFR 440.167 and allow family members to perform and be reimbursed for personal care services. Both of these approaches allow children who receive services in their homes to remain in a home setting and potentially reduce the need for hospital or nursing facility placement during a time when these facilities are being overwhelmed with COVID-19 patients.
Care coordination through telehealth for Medicaid managed care organizations (MCOs): Care coordination services are critical for children with special health care needs and are important services to improve health outcomes, reduce caregiver and patient burden, decrease health care costs, and strengthen systems of care for children with chronic and complex conditions. Currently, New Mexico’s Medicaid MCOs are required to conduct many care coordination activities (including initial screenings, needs assessments, and nursing facility level of care determinations) via home visits involving face-to-face interactions. As a result of COVID-19, New Mexico is requesting in its 1115 waiver application to allow its MCOs to continue to conduct their care coordination supports virtually – by telephone or, if possible, using video technology. This provision may help ensure that these valuable supports and services are continued and that children and youth with special health care needs (CYSHCN), in particular, are maintaining access to their care coordinators and care coordination services.
The National Academy for State Health Policy will continue to closely follow CMS responses to these waiver submissions and track any additional state 1115 waiver actions in response to the COVID-19 pandemic.
As states look for ways to ensure their systems are designed to support children during the pandemic, especially those with special health care needs, the National Standards for Systems of Care for CYSHCN can be a helpful resource. The standards address the core components of the structure and process of an effective system of care for CYSHCN such as access to care, eligibility and enrollment, and care coordination.
Many state waiver proposals during the pandemic are designed to improve aspects of the health care delivery system that are addressed by the National Standards, such as acknowledging the critical role families play in caring for children and children with special health care needs and allowing for flexibility in how care coordination is provided to best meet the needs of families and children. The standards can provide states with a framework to help ensure that key provisions and health care system components and protections are maintained during a time of disruption in the traditional health care delivery system.
States Launch Rapid Response Teams to Curb COVID-19 Outbreaks in Nursing Homes
In several states, nursing home staff and residents make up nearly half of residents who have died from COVID-19, including 55 percent of deaths caused by the coronavirus in Massachusetts. While hospitals’ personal protective equipment (PPE) shortages have been highlighted, less attention has been paid to the critical need for PPE and infection control expertise at nursing homes. In response, states are launching rapid-response initiatives to assess and stabilize patients and provide infection control recommendations and support.
Maryland and other states state are creating teams made up of National Guard members, local health department leaders, and providers reassigned from neighboring hospitals to bolster infection control and testing among nursing home residents and staff. During a recent webinar, Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19, sponsored by the National Academies of Sciences, Engineering, and Medicine and other organizations, experts from Maryland’s Institute for Emergency Medical Services Systems and Johns Hopkins University School of Medicine highlighted their joint efforts to address COID-19 outbreaks in nursing homes.
Using a Strike Team Approach
Maryland Gov. Larry Hogan created a strike team initiative in early April that involves Johns Hopkins University School of Medicine experts and providers, the state Department of Health, emergency medicine professionals, hospital system leaders, and members of the National Guard. The private-public partnerships were already cemented by years of hurricane disaster planning work.
The rising number of nursing home COVID-19 cases that required hospitalizations, “made clear we needed in-place infection control practices in skilled nursing facilities as well as the ability to assess and treat these patients in the environment in which they were familiar,” Maryland State Emergency Medical Services Director Timothy Chizmar explained during the webinar.
How Maryland’s strike teams work:
- When confronted with a COVID-19 case, nursing homes make requests for assistance to their county health departments, each request is then routed to the state’s emergency operations center.
- The center dispatches a health assessment team made up of physicians, nurses, and behavioral health specialists from the Maryland National Guard, supplemented by personnel from the state’s Department of Health and Human Services to assess the needs of the facilities and stabilize patients.
- The team triages patients into three categories, those requiring: hospitalization, moderate care provided by the facility, and monitoring of mild symptoms also provided in the nursing home.
- A clinical teams from a local hospital assists the facility with treatment and proper infection control.
“We’ve engaged early on with our state and federal partners to form these teams,” Chizmar explained. “Out of these visits, we generate reports that are provided to the state and facility. These records don’t serve as a means to penalize the facility, they’re designed to help reassure the facility and patients and provide recommendations to help the facility continue to care for patients.”
To date, Maryland has averted two large-scale evacuations of nursing homes besieged by COVID-19, according to Chizmar, by stabilizing patients and providing temporary staffing until staffing agencies provide needed resources. “One of our successes has been to prevent patients transferred unnecessarily (to a new facility, which is traumatic for frail and elderly patients) for lack of staffing,” he added. Chizmar pointed out that it remains a challenge to recruit certified nursing assistants and geriatric nursing assistants, even after the state has loosened regulations over job certifications to boost this critical workforce.
The Importance of Universal Testing
Megan Katz, director of Antimicrobial Stewardship at Johns Hopkins Bayview and assistant infectious disease professor at Johns Hopkins University School of Medicine, addressed the toll that limited testing has taken on resource-poor nursing homes.
At the beginning of the pandemic, she noted, regulations set a low threshold for testing residents for COVID-19 – they had to be symptomatic with a temperature of at least 99 degrees F. “(Nursing homes) would wait for supplies from the state, and then waited another couple days to get the results,” she said. In that period, more residents usually develop symptoms. “They were left chasing their tails,” she added.
Working with the state, Hopkins put a team together to develop a new universal testing approach when a facility reported a COVID-19 case. The team would go in and test both symptomatic and asymptomatic residents and staff in a unit or often the entire facility.
The results were shocking, she reported. In cases where one or two positive coronavirus cases were initially reported at a facility, testing of all residents and staff in the entire facility revealed that three-quarters of the entire facility staff and patients were positive for COVID-19, with 60 to 70 percent of them asymptomatic.
“What we’re trying to do is to get many different private hospitals and academic institutions and state and federal partners to work together to expand the ability to test in these facilities, so they can capture asymptomatic residents and staff who are contributing to a lot of this transmission,” she said.
Once infected and uninfected residents and staff are identified, facilities are able to implement targeted infection control practices and identify infected, asymptomatic staff who may be working at several long-term care facilities and spreading the infection, she noted.
Massachusetts has also implemented targeted universal testing, using a mobile testing program that tests both symptomatic and asymptotic residents and staff at nursing homes, rest homes, assisted living facilities, and group homes, staffed in part by the National Guard.
In an effort to expand its nursing home testing reach, the state recently sent 14,000 COVID-19 testing kits to nursing homes, but only 4,000 were returned. State health officials have paused the program and acknowledged that many nursing home staff lack the medical expertise to conduct the tests properly, underscoring the importance of having trained National Guard or health care providers on loan from local hospital systems present in nursing homes to train staff about proper test taking and infection control practices.
Lingering PPE Shortages in Nursing Homes
Even after state “strike teams” work with nursing homes and improve infection control practices, the lingering shortage of PPE can contribute to the continued spread of infection among residents and staff, noted Chizmar. Having the capacity to immediately test residents – instead of waiting for the state strike team to arrive – would help nursing homes identify the infected and enable them to conserve PPEs, so they are used with only infected patients. Webinar participants noted that in addition to hospitals, nursing homes should also be the recipients of masks and other PPE by local community groups.
Webinar speaker and Massachusetts resident Alice Bonner, director of Strategic Partnerships for CAPABLE and adjunct faculty member at Johns Hopkins University School of Nursing, noted that in Massachusetts every nursing home with a COVID-19 case is assigned to a state health officials who calls the facility daily to ask about staffing, PPE, best practices for infection control, and other problems in order for the state to respond to quickly and get the facility the support it needs.
Massachusetts also has a website to recruit nursing home employees, a resource line for nursing home residents and their families to learn more about their facility’s situation, and a weekly call between public health officials and nursing homes to identify problems and solutions.
States Implement Strategies to Safeguard Pregnant Women during the COVID-19 Pandemic
Across the nation, states are taking steps during the COVID-19 pandemic to protect pregnant women and their infants during delivery. States, whose Medicaid programs cover nearly half of all births in the United States, recognize the importance of ensuring all pregnant women have safe and healthy deliveries. The Centers for Disease Control and Prevention (CDC) reports that based on available information, pregnant women appear to have the same risk of infection as others.
Background
Nearly all pregnant women in the United States deliver their babies in hospitals, which are currently also treating numerous COVID-19 patients. As a result, states and health care facilities are taking extra precautions to support pregnant woman as they are treated and admitted for delivery to help protect them and their infants from COVID-19 and promote healthy birth outcomes.
Racial disparities already exist in maternal and infant mortality rates, and early COVID-19 reporting shows similar racial and ethnic disparities in mortality rates. The following are some actions states are taking to ensure healthy birth outcomes and support health equity for mothers during childbirth.
Supporting Women during Delivery
To ensure the safety of patients and health care workers during the pandemic, hospitals have begun limiting the number of visitors a patient may have. Because this policy resulted in women being alone during labor and delivery, states and hospital systems have taken steps to ensure women can have support systems in place during delivery.
- New York’s governor was the first to issue an executive order to ensure no person delivered a baby alone. The order, issued in late March, requires all hospitals to allow one support person in labor and delivery settings.
- In early April, Oregon’s governor issued an executive order that identified a spouse, partner, or other support person accompanying an individual giving birth as an essential individual for hospital visitation.
- Michigan went a step further when Gov. Gretchen Whitmer declared that pregnant women could have their partner and a doula accompany them during delivery if both individuals passed a health evaluation.
Supporting mothers during delivery is a critical step states can take to ensure safe deliveries and healthy outcomes for women and their newborns.
Expanding the Perinatal Workforce
With the spread of COVID-19, states are experiencing an unprecedented strain on their health care systems. To ensure a sufficient health care workforce, the federal government is providing new flexibilities to states, and states in turn are beginning to relax rules and regulations on provider requirements. Currently, at least six states (Maine, New Jersey, New York, Pennsylvania, Tennessee, and Texas) have emergency orders to expand midwifery care to pregnant women. These orders lift some regulations on out-of-state providers, continuing education requirements, and practice oversight.
In Pennsylvania, Gov. Tom Wolf has temporarily suspended a requirement that certified nurse-midwives file a collaborative agreement with the State Board of Medicine and wait until it is processed and approved before engaging in midwifery care. Nurse-midwives may now immediately begin providing care once they have a collaborative agreement with the state board, which bypasses the lengthy processing and approval steps.
In late March, Washington State submitted a 1115 waiver to allow some provider types, including doulas and community health workers, to provide Medicaid-reimbursable services, including preventive services, counseling, and case management during the public health emergency. The waiver seeks to establish a COVID-19 Disaster Relief Fund to stabilize the health care workforce as providers respond to COVID-19. Allowing doulas and community health workers to provide services and bill Medicaid would help ensure access to care and support services for pregnant women and promote health equity.
Monitoring for COVID-19 in Pregnant Women and Newborns
New information about the effects of COVID-19 on pregnant women and infants is emerging daily. Because of the unique needs of pregnant women, studies and data about the COVID-19 in the general population may not always apply to pregnant women. The Pregnancy Coronavirus Outcomes Registry (PRIORITY) Study, led by the University of California, San Francisco, is a nationwide registry designed to enhance understanding of how pregnant women are affected by COVID-19, including what their symptoms are, how long they last, and how COVID-19 may impact pregnancy and delivery.
Recently, Columbia University Irving Medical Center and New York-Presbyterian Allen Hospital in New York City, which has been hit hard by the pandemic, began screening all women admitted to delivery for COVID-19. Of 215 pregnant women screened, 33 women (15 percent) tested positive and most showed no symptoms, according to the New England Journal of Medicine report. As a result of the finding, more hospitals may consider screening pregnant women for COVID-19 when admitted for delivery.
As states begin to publicly report demographic information about COVID-19 cases, such as patient age, sex, and race, they can also choose to track and share information about COVID-19 in pregnant women and newborns, and perhaps identifying mother-to-baby transmission. Publicly reporting this information could help states and providers better understand best practices around treatment to ensure healthy pregnancies and outcomes. By also reporting race or ethnicity among pregnant women and infants with COVID-19, states can track and monitor disparities among these populations.
States are working rapidly to respond to the changing landscape for pregnant women during the pandemic. These policy measures are a few considerations to ensure women receive the care and support they need to have healthy pregnancies and deliveries during COVID-19. The National Academy for State Health Policy will continue to track state perinatal care policies, including Medicaid reimbursement for free-standing birth centers and home birth, postpartum coverage, and telehealth services for pregnancy-related care.
CARES Act Funds Help Consumers, but Create Health Coverage Eligibility Challenges for States
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) includes a Pandemic Unemployment Compensation benefit of $600 a week, which supplements traditional unemployment insurance (UI) benefits and provides an important source of additional financial support for individuals who qualify for these payments.
However, as highlighted in NASHP’s April 6, 2020 blog, Federal Guidance Needed to Clarify CARES Act Health Coverage Provisions, because these supplemental payments are counted as income for determining eligibility for marketplace subsidies – but not counted when determining eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) – there could be challenges for both individuals and states.
States are required to use streamlined applications across their health coverage programs and several states (CT, DC, CO, MA, MD, MN, RI, VT, and WA) have developed fully integrated eligibility systems shared by their Medicaid and state marketplaces. States must closely coordinate across these agencies as any changes to application instructions or questions could have ramifications for eligibility determinations between the programs.
The Centers for Medicare & Medicaid Services (CMS) recently released guidance that provides information on ways that states can identify the $600 weekly payments that are to be disregarded when determining Medicaid and CHIP eligibility. While the guidance gives states implementation flexibility, the options offered could be burdensome for both state Medicaid and CHIP agencies and individuals. Some of the issues include:
- Complications in coordinating with state unemployment offices: The guidance suggests that state Medicaid and CHIP agencies can work directly with their state unemployment agencies to determine which individuals will qualify for the additional payments. Yet, implementing a plan to identify these individuals in close coordination with unemployment agencies that are already significantly stressed with handling increased consumer demand is expected to be challenging for states.
- Challenges in implementing system changes: CMS notes that state unemployment agencies have the option to include the supplemental payments within their regular UI payments, or make the supplemental payments separately, which could help identify the $600 supplement for health coverage purposes. Separating the supplemental $600 payment from an individual’s regular UI may create additional work for the unemployment agency at a time when they are least able to accommodate additional work, but it could help both Medicaid and CHIP agencies (and although not referenced in the guidance, the marketplaces) to account for those separated funds in eligibility calculations.
CMS suggests that if state Medicaid and CHIP agencies can identify and document that all UI recipients will receive the additional payments, they will be able to program their eligibility systems to automatically reduce all UI income by $600 per week until the additional payments end on July 31, 2020. While the guidance indicates that states can potentially receive a higher federal match rate for making these system changes, quickly implementing them on a temporary basis will be administratively difficult for states – and it also assumes that states will have the ability to determine that all UI recipients are eligible for the additional payments.
- Relying on individuals to correctly report income could create eligibility determination complications: CMS indicates that states can choose to provide instructions in application forms or in their call center scripts to direct individuals to not report the $600 per week additional payments in their income for Medicaid and CHIP eligibility determinations. States can also ask that individuals self-attest about whether or not their UI income includes the $600 per week of additional payments. But some individuals may still mistakenly report the supplemental payments or not provide the correct information about whether their UI income includes the additional payments, which could negatively affect their Medicaid or CHIP eligibility. It could also hamper the ability of states to make accurate eligibility decisions and could result in state eligibility determination workers having to conduct extensive outreach to clarify applicants’ income information.
An important, remaining issue is that the CMS guidance does not address how states should align Medicaid and CHIP eligibility determinations with the fact the CARES Act requires the $600 supplemental payments to be counted as income when assessing eligibility for marketplace subsidies. This is particularly concerning for low-income consumers who are deemed ineligible for Medicaid and then are deemed eligible for low or zero marketplace subsidies because the inclusion of the supplemental payments has pushed them into an even higher income threshold. Concerns also remain about whether consumers might face penalties for inaccurately reporting income because of confusion caused by the different reporting requirements.
Additional federal guidance from the Center for Consumer Information and Insurance Oversight is needed to ensure that states can make accurate and timely eligibility determinations and that individuals are efficiently enrolled in health coverage.
States Race to Secure Home- and Community-Based Services during COVID-19
Updated May 7, 2020
In the past two months, 35 states* have rapidly amended their Medicaid home- and community-based services for older adults and their family caregivers to ensure access to long-term services and supports during the COVID-19 crisis. Under new federal rules, the states applied for Medicaid 1915(c) Appendix K waivers to make temporary or emergency-specific changes to protect enrollees.
Most of the states have also received approval for home- and community-based services waivers targeting other populations, such as children and people with intellectual/developmental disabilities. Of these 35 states, 19 (AK, AR, CO, DC, GA, IA, KS, KY, MA, MD, MN, MO, NM, NV, OR, SC, UT, VA, and WY) have Appendix K combination waivers that allow them to modify many waiver programs with one Appendix K application.
A Landscape of Flexibility
Overall, states are incorporating flexibilities to help Medicaid enrollees with long-term needs receive services, and some states have included flexibilities to help enrollees remain on the waivers during the emergency period. The major policy changes affect the following:
Telehealth: Nearly all of these states permit added flexibility for services, such as telehealth, or allowing services to be provided in alternative settings, such as private homes. To cut down on outsiders from entering family homes, many states are allowing for electronic and telephonic case management, service planning, evaluations, and monitoring, as well as electronic signatures or verbal approval to avoid face-to-face meetings.
Family caregiver supports: States often rely on family caregivers to provide home and community-based services to Medicaid enrollees. Recognizing this, some of these new COVID-19-related flexibilities directly assist family caregivers. Several states (AK, AZ, CA, CO, CT, DC, FL, GA, IA, KS, MS, NM, NC, ND, OK, SD, UT, and WV) are allowing family caregivers to provide services and, in some states, receive reimbursement when the hired aide is not available.
Meals and other services: To provide added support, many states (such as AZ, CO, CT, IA, KS, KY, LA, MA, MS, NC, ND, OK, SC, and UT) are expanding home-delivered meals. Several of these states (including AZ, CT, IA, MA, MS, SC, and UT) are allowing for non-traditional providers to provide the meals.
Providers: Many states are relaxing provider qualifications, including training, certification, and recertification requirements, to incorporate new, current, returning, or out-of-state providers. Several states also allow for flexibility on certain types of background checks, or qualifying relatives/family members to be direct care workers pending background checks. States (such as AK, AR, CO, DC, GA, KY, LA, MA, MS, NE, ND, OR, UT, and WA) allow for temporary payment rate increases for some providers to ensure continuity of services. Additionally, many states (such as AK, AZ, CO, DC, FL, GA, IA, KY, LA, MT, NM, NC, NY, OK, OR, UT, VA, PA, and WA) allow for retainer payments if a Medicaid enrollee or provider is not available because of COVID-19. These states often limit the payment to no more than a certain number of consecutive days, for example, 30 days.
Reporting: A number of states are loosening reporting requirements. For example, Kansas has requested a nine-month extension for its waiver reports and Oklahoma requested flexibility on its audit requirements.
State Medicaid programs have great flexibility in what services they provide and how they fund them, especially during the pandemic. For example, states can tap the temporary 6.2 percentage federal matching increase that was recently enacted in response to COVID-19. These Appendix Ks are an important tool for states because home- and community-based services waivers are serving people in the community who meet the level of care needs for services in nursing homes.
Next Steps
These policy changes are temporary, only lasting during the pandemic. After the COVID-19 crisis, it will be important to better understand the impact of these policy changes (telehealth, family caregiver supports, meals, provider flexibilities, and the ease of reporting) on cost and quality of life and determine if some of these changes should continue after the public health crisis abates.
The National Academy for State Health Policy (NASHP) developed an interactive map of state Appendix K waivers and will continue to update this information as more states make these modifications. In addition, NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living, published a report and interactive map on Medicaid information, training, and counseling resources for family caregivers.
*As of May 7, 2020, the 35 states that modified their aging and disability waivers were Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Utah, Virginia, Washington State, Washington, DC, West Virginia, and Wyoming.
New State Insurance Requirements in Response to COVID-19
COVID-19 has upended health care systems and states are revising health insurance rules to make sure consumers can maintain their health insurance coverage and access needed health care services during the pandemic. The chart below details recent state actions that:
- Limit consumer out-of-pocket costs for testing, treatment and out-of-network care;
- Facilitate access to and delivery of care, including rapid transfers to appropriate care settings without lengthy reviews and telehealth expansion;
- Enable consumers to maintain coverage despite economic hardship and COVID-19 diagnosis by relaxing premium payment requirements and waiving penalties; and
- Ease prescription refills and allow drug substitutes (formulary exemptions).
For more information, read the NASHP blog, States Protect Consumers’ Coverage and Improve COVID-19 Care Delivery through Insurance Reforms.
Toolkit: Upstream Health Priorities for Governors
Governors can control costs, advance their priorities, and enhance lives by improving the social and economic conditions that make up 80 percent of the factors affecting their residents’ health. Governors are uniquely positioned to maximize state resources to address the conditions affecting health by leading cross-agency and public-private collaborations, leveraging siloed state resources, and advancing evidence-based health policy approaches.
Tackling the Trifecta: State Approaches to Addressing Co-Occurring Substance Use Disorders, HIV, and Hepatitis C
In response to an increase in HIV and hepatitis C virus (HCV) infections in individuals with substance use disorders (SUD), including opioid use disorders (OUD), state policymakers are employing multifaceted strategies to address this syndemic, collaborating with public and private partners to prevent the spread of infectious disease and provide access to evidence-based treatment. This report explores innovative approaches Louisiana, New York, and West Virginia have taken to address co-occurring HIV and HCV infections and SUD – providing both rural and urban perspectives – and highlights their resourceful use of funding streams, leveraging of data, and advancing community readiness.
Background
The opioid epidemic has left no state untouched. In 2017, over 70,000 people died from drug overdoses,[1] 11.4 million people improperly used opioids, and 2.1 million people suffered from an opioid use disorder.[2] In addition to the thousands of overdoses and overdose deaths attributed to opioids, another result of the nation’s substance use disorder crisis has been an increase in rates of infectious diseases in people who inject drugs (PWID), including hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections, which can be transmitted by sharing contaminated syringes.[3]
Of particular concern is the fact that most new cases of hepatitis C are related to injection drug, and a previously consistent 25-year downward trend in rates of HIV infection among PWID is beginning to plateau.[4] The cumulative costs of treatment for these two conditions in the United States is quite high:
- The total annual cost of providing treatment and services to people living with HIV was $21.5 billion in FY 2019,[5]
- And the total annual health care cost for managing chronic hepatitis C in the is estimated to be $15 billion.[6]
In contrast, allocating the equivalent of the cost of treatment for a single person living with HIV ($400,000) to harm reduction[7] strategies would lead to the prevention of 30 new HIV cases – a significant cost-savings beyond the clear benefit of disease prevention for individuals and communities.[8] States at the forefront of addressing the opioid epidemic are increasingly interested in providing not only treatment, but also access to comprehensive prevention services in order to safeguard public health and make good use of limited resources.
Louisiana
In Louisiana, the number of opioid-related overdose deaths nearly tripled between 2012 and 2018 and exceeded 450 in 2018 – a 13.5 percent increase from the previous year.[9] Louisiana is experiencing a concurrent hepatitis C and HIV crisis:
- Between 2007 and 2017, 40,263 people received a hepatitis C diagnosis,[10] and the Louisiana Office of Public Health estimates that injection drug use is currently putting 112,424 more Louisianans at “very high risk” of infection.[11]
- There is significant co-morbidity within this population – in 2017, the state recorded at least 1,290 Louisianans who were co-infected with HIV and HCV.[12]
To address these challenges, Louisiana developed a statewide Hepatitis C Elimination Plan. The plan was created by the Louisiana Office of Public Health (OPH) in collaboration with the Louisiana Department of Health, the state Department of Public Safety and Corrections (DPS&C), the US Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Centers for Medicaid & Medicare Services (CMS), and state and national experts.[13] This comprehensive plan acknowledges the role of SUD in the state’s hepatitis C epidemic and the risks associated with intravenous drug use, and it aims to diagnose 90 percent and treat 80 percent of Louisianans living with hepatitis C within five years.[14] It also details a range of cross-cutting strategies that engage the private and public sectors, the health care industry, and community-level partners.[15]
Key features of Louisiana’s hepatitis C elimination strategy and related efforts to address SUD and its co-morbidities include:
- Restructuring reimbursement for hepatitis C treatment: Historically, Louisiana has paid for hepatitis C medications by the dose, incurring significant costs in its effort to pay for treatment for Medicaid enrollees or who are corrections-involved.[16] In response, the state’s HCV Elimination Plan features an innovative purchasing agreement between Louisiana and Asegua Therapeutics, a wholly owned subsidiary of Gilead Sciences Inc., a biopharmaceutical company.[17] Referred to as a “modified subscription model,” this agreement sets a capped cost for all HCV medication administered to the state’s Medicaid and corrections-involved populations.[18] The methodology incentivizes the state to identify and treat as many people as possible, as the marginal cost of each additional patient is essentially zero.[19]
Louisiana estimates that approximately 34,000 Medicaid enrollees and 5,000 incarcerated individuals in state corrections facilities have chronic hepatitis C; however, fewer than 3 percent of those 34,000 Medicaid enrollees were treated in 2018.[20] Under its agreement with Asegua, Louisiana aims to treat 10,000 Medicaid-enrolled and corrections-involved individuals by the end of 2020, and 30,000 individuals by 2024.[21] Preliminary claims data indicate that 2,900 people have initiated treatment since the July 15 start date, considerably more than the number of people treated in all of 2018.[22]
- Leveraging data to track and address co-morbid conditions: The Louisiana Public Health Information Exchange (LaPHIE)[23] was first implemented in 2008 as a partnership between OPH and Louisiana State University Health Care Services Division.[24] OPH maintains comprehensive HIV surveillance data that is updated daily through lab reporting. If a patient enters a participating hospital and a provider opens that patient’s electronic medical record to provide services, the provider will be notified if the patient has not received timely HIV care and prompted to take appropriate action.[25] LaPHIE is also bi-directional: any action taken by the provider with respect to the patient, whether it be a referral or a link back into care, is incorporated into the patient’s electronic medical record (EMR) and returned to OPH, which then updates the state’s HIV surveillance data.[26] This system is designed to strengthen care retention and improve disease management for patients living with HIV by engaging them at different care sites across the region. Improved HIV care management, with the aim of making a patient’s viral load undetectable, has the potential to not only improve an individual’s health status but also reduce the likelihood of HIV transmission to others.
Louisiana recently received funding to expand LaPHIE’s innovative functionality to include hepatitis C surveillance data and is now in the process of building out this new capacity.[27] State officials view the Hepatitis C Elimination Plan as a call to action to Louisiana hospital systems, whose participation in the LaPHIE surveillance system has dropped in recent years.[28]
- Focusing on high-risk populations: Louisiana has been successful by targeting limited state resources on particularly high-need populations:
HIV Prevalence and Diagnoses Attributed to Injecting Drug Use
Source: National Institute on Drug Abuse, Louisiana Opioid Summary, 2016.
- Individuals with SUD: In conjunction with its Hepatitis C Elimination Plan, Louisiana’s STD/HIV/Hepatitis Program updated its contracts with community-based organizations to require combined HIV, syphilis, and HCV screening and linkages to treatment for individuals with new diagnoses.[29]
- Individuals who are corrections-involved: OPH has worked closely with the Louisiana DPS&C to develop a treatment model for HCV and HIV, including linkage to care.[30] The DPS&C has offered opt-out HCV screening for all new individuals as they enter the state correctional system since 2008 and opt-out HIV screening for individuals upon release since 2014. OPH provides supplies and training for both of these initiatives.[31] Starting in October 2019, OPH launched a population-level screening project with DPS&C through which OPH offers screening for hepatitis A, B, and C, HIV, and syphilis in every state-run facility, and plans to complete screening all current state inmates by mid-2020.[32] OPH also supports a corrections-based, pre-release program leveraging Ryan White HIV/AIDS Part B funding from HRSA – specialists work with inmates living with HIV prior to their release and connect them with case management and support services in the communities to which they are discharged.[33] Louisiana is exploring the possibility of building a similar system for people with hepatitis C as part of its elimination plan.
- Individuals with HIV: Recognizing that people with SUD and related comorbidities often have insufficient dental care that can contribute to poor health outcomes, the Louisiana Health Access Program (LA HAP)[34] leveraged Ryan White Part B resources and worked with Guardian Dental to increase access to comprehensive oral health care for people with HIV.[35] Prior to this collaboration, people with HIV regularly encountered barriers to adequate dental care, including low annual caps, unexpected bills, and limitations on covered services.[36] The state was supported by the Health Services and Research Administration (HRSA) to structure a self-insured plan that would reduce unmet oral health care needs of people infected with HIV.[37] As a result, more than 2,000 individuals have been able to access a comprehensive set of services that address oral health care issues related to HIV infection.
West Virginia
West Virginia has one of the highest rates of drug overdose and mortality in the country. Compounding this crisis, injection drug use in West Virginia has contributed to the quintupling in new HIV diagnoses from 2014 to 2019.[38] Injection drug use is the second-leading cause of transmission for new HIV diagnoses for men and women in the state, according to most recent data from the National Institute on Drug Abuse (NIDA).[39] In 2018, Cabell County, on the state’s western edge, reported 81 new cases of HIV, which qualified it as an active HIV cluster – all 81 new HIV infections were tied to injection drug use.[40] As a very rural state that has been highly affected by the opioid crisis and its comorbidities, West Virginia has taken a decentralized approach in its harm reduction efforts, providing guidance and certification standards to communities to assist them in developing and administering programs at the local level.[41] Since 2011, when the state’s first harm reduction program opened,[42] West Virginia has navigated the challenges of operating syringe exchange programs, which is an evidenced-based, albeit sometimes controversial, approach.
HIV Prevalence and HIV Diagnoses Attributed to Injecting Drug Use
Source: West Virginia Opioid Summary, National Institute on Drug Abuse, 2016
Rural areas can face particular challenges in developing and sustaining harm reduction programs. Transportation is limited, confidentiality can be elusive in small towns, and the stigma associated with drug use can be heightened in rural, conservative communities.[43] In West Virginia, Kanawha County started the Kanawha-Charleston harm reduction program through its
department of health, offering syringe exchange in addition to comprehensive harm reduction services.[44] At its height, the program provided services to over 400 individuals weekly, effectively maximizing access to sterile syringes, preventing new HIV cases, and screening for HCV.[45] However, highly publicized public opposition, which was attributed to an uptick in crime and increase in discarded syringes in the area where the organization worked, ultimately led to the closure of the program in early 2019.[46]
West Virginia’s experience with the site in Kanawha County suggests that state support for community-level harm reduction programs can be most successful when they are community-specific.[47] Noted one West Virginia state official, “At the state level, you can’t just say, this program will work everywhere, or look at what other states have done and assume that it will work everywhere – state policymakers and public health officials have to tailor [the program] to the individual, unique communities that they serve.”[48] Those states in which syringe exchange (as a component of harm reduction) is more controversial are faced with the added challenge of finding the balance between the need for a comprehensive, evidence-based approach and implementing more limited models that are acceptable to local communities.[49] Providing messaging that helps to educate communities about the benefits of harm reduction services, including syringe exchange, may also be important in building community support.
Standardizing processes, engaging communities: In an effort to support implementation of harm reduction programs, West Virginia created Harm Reduction Program Guidelines and Procedures, which establish core certification requirements that these programs must meet in order to receive Department of Health and Human Resources’ funding.[50] To be certified, the program must outline all services provided, demonstrate compliance with state laws, rules, and local ordinances, and provide documentation of the involvement of the local health department.[51] The organization must also coordinate with local law enforcement and document any concerns they may have.[52] An integral step outlined in the guidelines is assessing the community’s readiness and building the community’s support prior to implementation.[53] The guidelines also offer several strategies to engage community stakeholders and encourage community buy-in prior to implementing harm reduction programs.[54] Although these programs do not need to be certified in order to operate in West Virginia, sites that complete the certification process are more likely to programmatically align with the state’s eight core strategies for successful harm reduction programs:
- Build community support prior to implementation of a harm reduction program and maintain support for the duration of the program;
- Conduct routine program and process evaluation;
- Have a detailed community syringe retrieval in place for non-sterile syringes found in the community;
- Emphasize harm reduction as a Pathway to Care;
- Emphasize increasing stability and reducing risk among harm reduction participants and fostering supportive relationships with harm reduction program personnel;
- Train caring and supportive staff to provide consistent messaging of safe injection practices, overdose prevention, and infectious disease screening;
- Recommend dispensing syringes in person, not via proxy; and
- Have a mechanism to get patients in treatment when they are ready.[55]
Incremental changes: Despite the programmatic and public relations challenges that harm reduction programs have sometimes faced in West Virginia, communities are gradually embracing these programs. New sites are opening, existing programs are experiencing higher client engagement,[56] and the state has allocated State Treatment Response and State Opioid Response federal grant funding to support harm reduction programs in recent years.[57] This community-by-community approach has allowed the state to increase access to treatment for SUD and prevent the spread of infectious diseases.[58] In its work with local communities, West Virginia has also leveraged CDC’s and HRSA’s HIV/AIDS Bureau’s HIV cluster detection and response service in order to identify at-risk communities, assist local health departments as they identify prevention and service system gaps, and allocate resources accordingly to be responsive to new outbreaks.[59]
New York
New York has a long history of innovation in preventing the spread of infectious disease associated with injection drug use. In particular, the state invested early in its Syringe Exchange Program,[60] creating the foundation for a comprehensive harm reduction approach. Through these efforts, only 2 percent of new HIV infections per year are reported among PWID.[61] Gov. Andrew Cuomo’s Ending the Epidemic plan includes achieving zero new HIV infections among PWID and a plan for the first-ever decrease in HIV prevalence in New York by the end of 2020.[62]
HIV Prevalence and HIV Diagnoses Attributed to Injection Drug Use
A lasting result of this early investment is New York’s Harm Reduction Initiative, a program funded by the state’s Department of Health, AIDS Institute.[63] This program funds comprehensive harm reduction programs for individuals living with SUD and the people and communities that support them, including New York’s innovative Drug User Health Hubs.[64]
*New York Opioid Summary, National Institute on Drug Abuse, 2016
Supporting integrated models of care: Drug User Health Hubs are enhanced syringe exchange programs that offer a broad range of services, driven by the particular needs of the population in the surrounding community.[65] Hubs are intended to increase access to physical and behavioral health services, including medication-assisted treatment (MAT) for people with opioid use disorder (OUD).[66] Services are offered at hub sites and through referral.[67] Hubs provide services and support with an emphasis on prevention and responding to opioid overdose.[68] Services can include:
- Medical services: Includes accessible buprenorphine; wound care; HCV testing, diagnosis, and treatment; and rapid assessment of a client’s needs.
- Opioid overdose prevention/aftercare for an overdose: Includes training and provision of naloxone overdose reversal kits; training on safer injection practices and provision of syringes; facilitation of appropriate referrals from Emergency Departments and first responders, etc.
- Law enforcement diversion: Includes the law enforcement diversion of PWID who have committed low-level infractions to Drug User Health Hubs.
- Anti-stigma activities: Features hub employees who engage with local providers to encourage a harm reduction focus in their provision of care to PWID, and with local communities to destigmatize injection drug use and create a welcoming environment for all community members.[69]
The goal of New York’s hubs is to transform the state’s syringe exchange programs into locations that can provide comprehensive, easily accessible medical services to PWID.[70] In many health care settings, patients are required to receive psychosocial counseling in order to be prescribed medications to treat OUD.[71] Recognizing that this can be a substantial disincentive to getting treatment, New York’s Department of Health (NYSDOH) began a buprenorphine-first approach, providing medications for treating OUD as a first step, without initially requiring other services.[72] Individuals can receive buprenorphine only, or opt to concurrently access services that can include counseling and other medical treatments as needed, such as those for soft tissue infections, hepatitis C, HIV, and diabetes.[73] As part of the state’s Strategy to Eliminate Hepatitis C, the NYSDOH Bureau of Hepatitis Health Care funds patient navigator positions in seven different hubs in upstate New York.[74] These individuals provide guidance to people living with hepatitis C as they navigate the health care system, and help link them to care and treatment.[75]
Leveraging Medicaid for prevention: In 2018, New York implemented a Medicaid state plan amendment (SPA) that allows the state’s harm reduction programs to deliver certain Medicaid reimbursable services, including medication management and treatment adherence counseling for MAT, HIV and HCV infections, mental health conditions, and pre-exposure prophylaxis (PrEP) to prevent HIV infection.[76]
A product of a partnership among the NYSDOH AIDS Institute’s Office of Drug User Health, the Office of Health Insurance Programs, and community partners, the SPA came to fruition after extensive negotiation and revision.[77] Initially, it was required to have a physician perform the harm reduction services covered under the SPA, but the state was able to modify staffing requirements, recognizing that many harm reduction programs in the state do not have medical providers on staff.[78] The approved SPA permits licensed clinical social workers, certified peers, and direct service providers with relevant experience to provide Medicaid-reimbursable harm reduction services under the SPA.[79]
The NYSDOH also recently amended the requirements that community-based organizations must satisfy in order to become licensed health care facilities, allowing organizations such as syringe exchange programs, to provide and bill Medicaid for primary care services.[80] Syringe exchange programs have historically been unable to directly deliver primary health care services and have been required to contract out these services in order to deliver them on-site – a model that was not financially sustainable for most.[81] The change permits these organizations to fully integrate Medicaid-reimbursable primary care, including HCV and HIV screening, assessment, and treatment within the harm reduction setting.[82] State officials see the ability to deliver primary care in these nontraditional settings as necessary to achieve the goal of disease elimination.[83]
Considerations for States and Conclusion
While states have taken different approaches to addressing the opioid crisis and its related increase in infectious disease incidence, these three states’ approaches provide some common themes that can be implemented elsewhere:
- Robust data is critical to address the complex co-morbidities associated with SUD. Unlike HIV surveillance, which remains relatively well-funded and robust, hepatitis C surveillance typically does not have consistent funding nor a robust infrastructure across states. However, some states are taking steps to improve their infrastructure and leverage new technology. For example, Louisiana is adapting its HIV surveillance strategy and standards to include hepatitis C surveillance, and in so doing has turned a passive registry into an “active and rigorous system of care,” according to one state public health official. Similarly, New York is in the process of improving its hepatitis C surveillance infrastructure as part of its statewide elimination plan. In West Virginia, the CDC’s HIV cluster detection and response team has been an important resource to help the state accurately track HIV outbreaks and appropriately allocate resources.
- Medicaid plays an important role in prevention and treatment. One Louisiana state official observed, “Our plan to eliminate hepatitis C hinged on the increased insurance coverage that Medicaid expansion has provided our residents.” Medicaid expansion in Louisiana was critical in expanding access to comprehensive HIV prevention and treatment, as newly eligible Medicaid beneficiaries were able to transition away from reliance solely on the Ryan White HIV/AIDS program. Louisiana used Medicaid funding to shift and alleviate costs and was able to provide expanded services to people with HIV. New York, similarly, has been able to leverage Medicaid to create a harm reduction benefit, which has expanded the ability of the state’s syringe exchange sites to engage in prevention activities.
- Solutions must be tailored to local needs. Because the OUD crisis looks very different in different places, policymakers must be responsive to specific drivers and factors that shape a community’s experience. In response to the challenges it experienced in implementing sustainable harm reduction programs in West Virginia, the state developed certification guidelines that it ties to state funding. In so doing, the state ensures that the majority of harm reduction programs in West Virginia assess and engage with their local communities prior to implementation. Similarly, one of the mandates of New York’s Drug User Health Hubs is to work with the communities in which they operate to reduce the stigma associated with substance use, and better involve community members who inject drugs.
Conclusion
The concurrent increase in the incidence of blood-borne infectious diseases is just one consequence of an OUD crisis that has had a far-reaching impact on the nation. By implementing evidence-based, community-tailored prevention and treatment policies, states can prevent new infections, better address co-morbid SUD and infectious diseases, and reduce state costs. Through coordination and targeted resources, states are developing sustainable prevention and treatment policies that can address the complexity of factors at the intersection of SUD and infectious disease.
Notes
[1] “Opioid Overdose,” Centers for Disease Control and Prevention, October 18, 2019, https://www.cdc.gov/drugoverdose/index.html.
[2] “The opioid epidemic and emerging public health policy priorities,” American Medical Association, October 31, 2019, https://www.ama-assn.org/delivering-care/opioids/opioid-epidemic-and-emerging-public-health-policy-priorities.
[3] “Persons Who Inject Drugs (PWID)s,” Centers for Disease Control and Prevention, July 19, 2018, https://www.cdc.gov/pwid/index.html.
[4] “Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, May 23, 2019, https://www.cdc.gov/ssp/syringe-services-programs-summary.html.
[5] “U.S. Federal Funding for HIV/AIDS: Trends Over Time,” Kaiser Family Foundation, March 2019, https://www.kff.org/hivaids/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/.
[6] “Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, May 23, 2019, https://www.cdc.gov/ssp/syringe-services-programs-summary.html.
[7] “Department of Health and Human Services Implementation Guidance to Support Certain Components of Syringe Services Programs, 2016,” Department of Health and Human Services, 2016, https://www.hiv.gov/sites/default/files/hhs-ssp-guidance.pdf.
[8] “Harm Reduction for HIV Prevention,” Avert, March 2019 https://www.avert.org/professionals/hiv-programming/prevention/harm-reduction.
[9] Louisiana Department of Health Opioid Steering Committee, “Louisiana’s Opioid Response Plan,” Louisiana Department of Public Health, 2019, http://ldh.la.gov/assets/opioid/LaOpioidResponsePlan2019.pdf.
[10] Sam Burgess, “Louisiana’s Hepatitis C Elimination Plan,” Louisiana Department of Health, 2019, https://www.nastad.org/sites/default/files/Uploads/2019/2019-am-burgess.pdf.
[11] Ibid.
[12] “Louisiana Hepatitis C Elimination Plan: 2019-2024,” Louisiana Department of Health, August 2019, https://www.louisianahealthhub.org/wp-content/uploads/2019/08/HepCFreeLA.pdf.
[13] Ibid.
[14] Ibid.
[15] Ibid.
[16] Ted Alcorn, “Hepatitis C Drugs may Serve as Model,” The Wall Street Journal, September 13, 2019, https://www.wsj.com/articles/louisianas-deal-for-hepatitis-c-drugs-may-serve-as-model-11568347621.
[17] Ibid.
[18] Ibid.
[19] Gretchen A. Meier, “Using the Drug Pricing Netflix Model to Help States Tackle the Hep C Crisis,” USC Leonard D. Schaeffer Center for Health Policy and Economics, August 16, 2019, https://healthpolicy.usc.edu/article/using-the-drug-pricing-netflix-model-to-help-states-tackle-the-hep-c-crisis/.
[20] “Solicitation for Offers for Pharmaceutical Manufacturers to Enter Into Contract Negotiations to Implement Hepatitis C Subscription Model,” Louisiana Department of Health, http://ldh.la.gov/assets/oph/SFO/SFOWrittenAnswersManufacturers.pdf.
[21] Gretchen A. Meier, “Using the Drug Pricing Netflix Model to Help States Tackle the Hep C Crisis,” USC Leonard D. Schaeffer Center for Health Policy and Economics, August 16, 2019, https://healthpolicy.usc.edu/article/using-the-drug-pricing-netflix-model-to-help-states-tackle-the-hep-c-crisis/.
[22] Interview with Louisiana.
[23] The Louisiana Public Health Information Exchange was originally funded by HRSA.
[24] Interview with Louisiana.
[25] Ibid.
[26] Ibid.
[27] Ibid.
[28] Ibid.
[29] “Louisiana Hepatitis C Elimination Plan: 2019-2024,” Louisiana Department of Health, August 2019, https://www.louisianahealthhub.org/wp-content/uploads/2019/08/HepCFreeLA.pdf.
[30] Interview with Louisiana.
[31] Ibid.
[32] Ibid.
[33] Ibid.
[34] Louisiana Health Access Program, 2018, https://www.lahap.org/dental/.
[35] Interview with Louisiana.
[36] Ibid.
[37] Ibid.
[38] Catherine Slemp, “Health Advisory # 162,” West Virginia Department of Health and Human Services, October 2019, https://oeps.wv.gov/healthalerts/documents/wv/WVHAN_162.pdf.
[39] “West Virginia Opioid Summary,” National Institute on Drug Abuse, March 2019 https://www.drugabuse.gov/opioid-summaries-by-state/west-virginia-opioid-summary.
[40] Kyle Swenson, “Unraveling an HIV cluster,” The Washington Post, November 3, 2019, https://www.washingtonpost.com/national/unraveling-an-hiv-cluster/2019/11/03/66cf4526-f5af-11e9-8cf0-4cc99f74d127_story.html.
[41] “Harm Reduction Program (HRP) Guidelines and Certification Procedures,” West Virginia Bureau for Public Health, 2018, https://oeps.wv.gov/harm_reduction/Documents/hcp/HRP_Guidelines_2018.pdf.
[42] “West Virginia Harm Reduction Programs At-A-Glance,” West Virginia Office of Epidemiology and Prevention Services, 2018, https://oeps.wv.gov/harm_reduction/documents/about/wv_hrp.pdf.
[43] Sean T. Allen et al., “Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs,” Harm Reduction Journal, May 21, 2019, https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-019-0305-7.
[44] Kara Leigh Lofton, “Diving Deep into Harm Reduction Part 1: Why W.Va’s Largest Needle Exchange Closed,” West Virginia Public Broadcasting, November 26, 2018, https://www.wvpublic.org/post/diving-deep-harm-reduction-part-1-why-wva-s-largest-needle-exchange-closed#stream/0.
[45] Ibid.
[46] Ibid.
[47] Interview with West Virginia.
[48] Ibid.
[49] HHS resources for Syringe Services Programs may be accessed here: https://www.hiv.gov/federal-response/policies-issues/syringe-services-programs.
[50] West Virginia Harm Reduction Programs At-A-Glance,” West Virginia Office of Epidemiology and Prevention Services, 2018, https://oeps.wv.gov/harm_reduction/documents/about/wv_hrp.pdf.
[51] “Harm Reduction Program (HRP) Guidelines and Certification Procedures,” West Virginia Bureau for Public Health, February 1, 2018, https://dhhr.wv.gov/oeps/harm-reduction/Documents/HRP_Guidelines_2018.pdf.
[52] Ibid.
[53] Ibid.
[54] Ibid.
[55] Ibid.
[56] Bureau for Public Health, “White Paper: The Need for Harm Reduction Programs in West Virginia,” West Virginia Department of Health and Human Resources, November 6, 2017, https://oeps.wv.gov/harm_reduction/documents/training/hrp_white_paper.pdf.
[57] “Announcement of Funding Availability – Harm Reduction,” West Virginia Department of Health and Human Resources, Bureau for Public Health, May 17, 2019, https://dhhr.wv.gov/bhhf/AFA/Documents/AFA%20FY%2019/Harm%20Reduction%20AFA%20FINAL.pdf.
[58] Bureau for Public Health, “White Paper: The Need for Harm Reduction Programs in West Virginia,” West Virginia Department of Health and Human Resources, November 6, 2017, https://oeps.wv.gov/harm_reduction/documents/training/hrp_white_paper.pdf.
[59] Interview with West Virginia.
[60] “Policies and Procedures: Syringe Exchange Programs,” New York State Department of Health Aids Institute, September 2016, https://www.health.ny.gov/diseases/aids/consumers/prevention/needles_syringes/syringe_exchange/docs/policies_and_procedures.pdf.
[61] Interview with New York.
[62] “Ending the AIDS Epidemic in New York State,” New York State Department of Health, January 2020, https://www.health.ny.gov/diseases/aids/ending_the_epidemic/.
[63] “Drug User Health,” New York State Department of Health, August 2017, https://www.health.ny.gov/diseases/aids/general/about/substance_user_health.htm.
[64] Ibid.
[65] Ibid.
[66] Ibid.
[67] Ibid.
[68] “Drug User Health – Drug User Health Hubs,” New York State Department of Health, October 2019, https://www.health.ny.gov/diseases/aids/consumers/prevention/.
[69] “Drug User Health,” New York State Department of Health, August 2017, https://www.health.ny.gov/diseases/aids/general/about/substance_user_health.htm.
[70] Interview with New York.
[71] Ibid.
[72] Ibid.
[73] Ibid.
[74] Interview with New York.
[75] “New York State Hepatitis C Elimination Task Force,” New York State Department of Health, April 2019, https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/elimination.htm.
[76] “New York State Plan Amendment,” Centers for Medicare and Medicaid Services, August 10, 2017, https://www.health.ny.gov/regulations/state_plans/status/non-inst/approved/docs/app_2017-08-10_spa_13-19.pdf.
[77] Interview with New York.
[78] Ibid.
[79] “Harm Reduction Services,” New York State Department of Health, May 2018, https://www.health.ny.gov/health_care/medicaid/redesign/2018/docs/harm_reduction.pdf.
[80] Interview with New York.
[81] Ibid.
[82] Ibid.
[83] Ibid.
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Louisiana, New York, and West Virginia state officials who generously shared their time and insight during the preparation of this report. The authors also thank Trish Riley and Kitty Purington of NASHP, as well as Carolyn Robbins and her colleagues at the Health Resources and Services Administration for their guidance and helpful feedback.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. The information or content and 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. 
