Population Health – Page 12 – The National Academy for State Health Policy

Medications for Opioid Use Disorder (MOUD) Provided in State Prisons, March 2021

March 4, 2021/in Opioid Center Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP Staff

Eye on the Storm: Two NASHP Staffers in Texas Reflect on Weathering Winter Storm Uri

March 1, 2021/in Policy Texas Blogs, Featured News Home COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health /by Eskedar Girmash and Sarah Lanford

Last month, Winter Storm Uri caused catastrophic power outages across Texas. National Academy for State Health Policy staff Eskedar Girmash and Sarah Lanford, who work remotely from Dallas and Houston during the pandemic, were both without power for four days as temperatures fell to single digits and they lost access to water. At least 58 people died trying to stay warm, and more than 13 million Texans lost access to safe drinking water and were under a boil-water notice for days after the storm passed.

Sarah Lanford: We lost power at my home in Houston at 1:30 a.m. on Monday, Feb. 15, and did not regain it until mid-day Thursday, Feb. 18. As a lifelong Texan, I’m used to being without power for weeks at a time after hurricanes, but never in cold weather. I have never been as worried for my safety as I was on Monday evening, when the temperature in our house dipped below 40 degrees and we could not get warm despite many layers of clothing and blankets. We eventually decided to sit in the car in our driveway for the remainder of the evening, where heaters and seat warmers kept us warm until we were able to safely make our way to my grandmother’s house. Fortunately, my family is in a closed COVID-19 bubble, which we were able to maintain throughout the week, and my grandmother had already received her vaccine. The following day, we sat near my grandmother’s fireplace under layers of blankets. We tried to conserve our phones’ batteries in case we needed to communicate with anyone, and we read books by flashlight. Power came on and off, but we never knew when it would come or go. We flushed the toilet sparingly and did not shower for days.

Throughout the week, the only time I heard from local or state leaders was when Harris County was placed under a boil notice. We couldn’t help but laugh when we got that alert – we had lost access to most of our water and even if we had water, we did not have the electricity required to boil it. The absence of local and state leadership was jarring. It felt like we had been abandoned.

Eskedar Girmash: I grew up in the City of Dallas and later moved to the northern suburbs. I was used to everything shutting down or at least drastically slowing at the sight of snow, but never experienced such mass infrastructure failure as last week. Like Sarah, I lost power late Sunday night and did not regain it fully until Thursday. I spent days charging my phone in my car, wearing layers of clothes and blankets, finding whatever cardboard boxes and newspapers around to make a fire in our fireplace, and making sure my two-year-old niece was as warm as she could be. Luckily, we had a close family friend who offered up her home to us for warmth on Tuesday. Though we were warm, we were also met with the confounding variable of COVID-19 as there were other families seeking warmth at her home. It was dystopic, roads were dangerously iced over, all businesses were shuttered and dark, grocery stores were empty, and families were suffering.

As I write this, it is now 74 degrees outside, making the realities of last week seem like a distant disaster. However, so many families are now left with new disasters, including extensive home damage, medical bills, and contaminated water. This storm and our infrastructure failures make me increasingly aware of the immediacy of addressing climate change and its effects on public health. Further, it reinforced my understanding that it is often everyday people who are forced to step up and care for their communities when disaster strikes. Community organizers – particularly Black and Latinx women – across the Dallas-Forth Worth metroplex are the true heroes of last week’s disaster. They led life-saving efforts when local and state leaders were nowhere to be found.

Overlapping Crises

Sarah Lanford: The energy crisis happened against the backdrop of a pandemic that has already wreaked havoc on Texas, causing more than 40,000 deaths. Texans were left with little ability to avoid contact with people outside their household as many people gathered with neighbors or went to large warming centers to avoid freezing temperatures. The bad weather closed COVID-19 vaccination sites, and Harris County rushed to distribute more than 8,000 doses after a storage facility lost power Monday and officials urged people to stay off icy roads. It will likely take the state three weeks to recover from the week-long delay in vaccinations.

Impact on Seniors and Adults with Chronic Health Conditions

Sarah Lanford: After we regained power, I made welfare calls to seniors across the state as part of a community-led effort to ensure people had access to drinking water and were able to stay warm. At the end of those calls, we inquired about other immediate needs. Again and again, I heard from people who were either unable to get to the pharmacy to refill prescriptions or who were in dire need of dialysis. Many pharmacies were closed due to power outages, and those that were open could not obtain shipments due to icy roads. Nearly all outpatient dialysis centers in the state were closed due to power outages, and many hospitals were unable to perform inpatient dialysis after they lost access to water. This put the nearly 50,000 people in the state suffering from kidney failure in life-threatening situations. Power outages also affected access to medications that require storage at specific temperatures, such as insulin, and rendered life-sustaining medical equipment, such as oxygen, inoperable.

Impact on Children

Eskedar Girmash: As with seniors and adults with chronic health conditions, many children and youth with special health care needs (CYSHCN) rely on home health care services, refrigerated medications, and electronically powered medical equipment. Power outages and other infrastructure failures resulted in the loss of many services, creating a surge in pediatric hospital admissions. Cases of hypothermia, carbon monoxide poisoning, frostbite, and car accident injuries also contributed to a rise in pediatric hospitalizations and fatalities. Some children’s hospitals were met with their own power and water outages, resulting in additional challenges in caring for newly-admitted children on top of the patient care challenges brought on by the COVID-19 pandemic.

Schools also suffered major infrastructural failures. Loss of power, water, and resulting damage interrupted student’s access to education, and the many additional essential services schools provide, such as meals, mental health, and physical health supports. There were over 130 burst pipes across schools in Dallas Independent School District, the second-largest school district in Texas. As a result, virtual and in-person school interruptions are in place until March 1 for schools that experienced extensive damage.

Inequities and Mutual Aid

Eskedar Girmash: As with all public health disasters, Winter Storm Uri laid bare many racial and class inequities that exist in our systems. Because of long-lasting systemic racism, such as redlining, many low-income Black and Latinx communities suffered disproportionate losses from the storm. To address these stark racial and ethnic inequities, mutual aid groups across the Dallas-Fort Worth metroplex sprang into action, becoming the main form of disaster relief for our communities.

On Saturday after the storm, I volunteered with mutual aid groups in Dallas to cook meals and deliver groceries for families in need. Hundreds of people came out at various kitchens and sites across the city in a mutual effort to care for our communities. All individuals were masked, frequently washed hands, and following COVID-19 precautions. It was both incredible and devastating to witness how communities and organizers stepped up to take care of their own during a time when government was absent and slow to respond. Organizations like Feed the People Dallas, Lucha Dallas, and Not my Son helped place families who were experiencing freezing temperatures and damage to their homes in hotels and organized hot meal, grocery, hygiene, and other resource deliveries. Other organizations like North Texas Rural Resistance provided essential resources to low-income rural communities who were also disproportionately affected by the residual effects of the storm. These organizations are continuing their community-based efforts following the initial impact of the storm as many families remain without clean water and livable homes.

The Aftermath and Looking Ahead

Winter Storm Uri is proof that climate change leads to public health emergencies. Though power has been restored to most Texas homes, many are now dealing with the financial and logistical hardships of home repairs, debt accrued from emergency hospitalizations, and wage losses contributing to financial and mental health burdens on families, especially low-income families with children and those caring for children with special health care needs. Damages to homes and businesses, cleanup costs, and lost wages are estimated at $50 billion.

As state leaders begin to address the aftermath of the storm and look ahead for ways to avoid a similar crisis in the future, these questions arise:

How can public health agencies work to advise and collaborate on rebuilding energy and home infrastructure across Texas and particularly focus on strengthening infrastructure in low-income, rural, and predominately Black, Asian-American, Latinx, and Native American communities?
How can government agencies collaborate to develop resources and access to mental and physical health supports for CYSHCN and Black, Latinx, and Native American children who were disproportionately affected by the storm?
How will public health agencies strengthen their focus on preparation for climate change disasters?
How will public health and safety agencies better prepare for climate change disasters so they can respond immediately and effectively?
What measures will be implemented to ensure that vulnerable populations are prioritized in disaster preparation and relief measures?

Some have said this is a once-in-a-lifetime storm, but this is the second time in a decade that Texans have experienced massive power outages after extreme winter weather. In 2011, a similar storm led to widespread power outages across the state. Policymakers failed to heed lessons from that storm and weatherize the power infrastructure, and last week Texans paid the price. Preparing for climate change is imperative. The climate crisis is life-threatening issue and requires public action to keep Texans safe.

New Jersey Medicaid Implements New Policies to Improve Maternal Health

March 1, 2021/in Policy New Jersey Blogs, Featured News Home Health Equity, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health /by Taylor Platt

New Jersey, like many states, faces rising maternal mortality rates and racial disparities. A recent review of pregnancy-related deaths in the state from 2009 to 2013 found 46.2 percent of deaths occurred in Black women, compared to 26.9 percent in White women. With approximately 40 percent of New Jersey’s births covered by Medicaid, the governor’s office recently announced the following Medicaid initiatives to improve maternal health and reduce overall health care costs.

Medicaid Coverage of Doula Care: Legislation passed in 2019 enabled Medicaid coverage of doula services in the state. A doula is a trained professional who provides continuous physical, emotional, and informational support to the birthing parent throughout the perinatal period. Doula care has been shown to reduce cesarean rates, improve birth experiences, and improve birth outcomes. Once doulas receive the community-based doula training from an approved program, they are able to enroll as fee-for-service providers and with Medicaid managed care organizations.

New Jersey has designated two levels of doula care eligible for reimbursement, standard and enhanced care.

Services for standard care include up to eight perinatal visits and attendance during labor and delivery with a reimbursement rate of $800.08.
Enhanced care is for members age 19 or younger and services include 12 perinatal visits and attendance during labor and delivery with a reimbursement of $1,066.
Additionally, for both levels of care there is an $100 incentive for postpartum, follow-up visits.

In order to receive the incentive payment, doulas must provide a postpartum service visit within six weeks of delivery and use the code 99199 HD U8 for billing. An obstetric clinician follow-up visit must occur within six weeks of delivery to receive the incentive payment but is not required for doulas to receive reimbursement for other services. Doulas serving Medicaid enrollees must be trained to provide culturally competent care that supports the diversity of the members and assist members with community-based services to improve health outcomes. Currently, Minnesota and Oregon cover doula services for all Medicaid recipients and New York has a pilot program running in two counties. Additionally, as directed by their state legislatures, Virginia and Washington State have submitted reports and studies on implementation of Medicaid reimbursement.

Increased Payments to Certified Nurse Midwives: In an effort to increase access to quality maternity services, New Jersey Medicaid has also increased the reimbursement rate of certified nurse midwives (CNMs) to be equivalent to 95 percent of the current rate for physicians who provide prenatal, labor and delivery, and postpartum services. A CNM is an advanced practice registered nurse (with a master’s degree in nursing) who specializes in the care of women throughout their life course, including pregnancy, childbirth, and the postpartum period. According to the most recent Pregnancy Risk Assessment Monitoring System (PRAMS) data, 33.1 percent of Black, non-Hispanic mothers in New Jersey reported receiving late or no prenatal care, compared to 14.6 percent of White, non-Hispanic mothers. The increase in reimbursement rates for CNMs is designed to build a larger network of midwives and increase access to quality pregnancy-related care for mothers and babies in New Jersey. As of 2013, approximately 34 states and Washington, DC, reimburse CNMs at 90 to 100 percent of the rate of earned by practicing physicians.

Medicaid Will Not Pay for Non-Medically Necessary, Early-Elective Deliveries (EED): In 2019, New Jersey passed a law that no provider will be approved for reimbursement by Medicaid for a non-medically indicated, early-elective delivery performed at a hospital on a pregnant woman earlier than the 39th week of gestation. Scheduled cesarean sections or medical inductions performed prior to 39 weeks carry risks for both mother and baby. Overall, New Jersey’s rate of surgical births (cesareans) is 30.3 percent. The benefits of non-surgical birth include shorter hospital stays, reduced infection rates, lower blood clot risk, and fewer infants born with difficulty breathing. Currently, 20 states have reduced or eliminated payment for procedures (EEDs, elective inductions, and non-medically necessary cesarean sections) that do not follow clinical guidelines. The new Medicaid policy in New Jersey supports education campaigns and hospital initiatives that are already in place to lower non-medically necessary EEDs. The new policy will not affect mothers who have medical indications for early delivery.

Providers Required to Complete the Perinatal Risk Assessment (PRA) Forms: In 2019, the state passed a law requiring Medicaid providers to complete PRAs during the first prenatal visit for all Medicaid enrollees. The tool is used to identify demographic, medical, and psychosocial factors that can help determine case management plans for pregnancies. The PRA form has been updated to included assessment of alcohol and drug use and COVID-19-related challenges. The state will use the data collected from the PRAs to analyze and identify risk factors among pregnant Medicaid enrollees in the state.

State Medicaid programs have the opportunity to implement policy changes, similar to New Jersey’s, that support improving maternal and infant health outcomes. Given current budget challenges in states, funding can be challenging, but these policy changes can result in cost savings by lowering cesarean rates, decreasing length of stays in hospitals, and improving overall birth outcomes. The National Academy for State Health Policy (NASHP) will continue to track state maternal and child health policies.

American Rescue Plan Could Significantly Enhance Health Insurance Coverage

March 1, 2021/in Policy Blogs, Featured News Home CHIP, Consumer Affordability, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Relief and Recovery, State Insurance Marketplaces /by Christina Cousart and Anita Cardwell

Last week, the House passed the American Rescue Plan Act of 2021 (ARPA). The $1.9 trillion relief package’s current proposals would change health coverage programs, including Medicaid, health insurance marketplaces, and continuation coverage offered through the Consolidated Omnibus Budget Reconciliation Act (COBRA).

If enacted, the changes could have significant ramifications for states and individuals served by these programs. States should be prepared to act quickly to implement and/or respond to the changes, some of which will be effective immediately upon passage.

ARPA is now before the Senate, which may make modifications and will review its provisions to determine if they meet budget reconciliation rules. Both House and Senate leadership have expressed strong interest in quickly passing the legislation, with passage possible by mid-March.

The following highlights key proposed Medicaid and Children’s Health Insurance Program (CHIP) changes as well as provisions designed to help increase access to affordable care for individuals who have lost employer-sponsored insurance.

Key Medicaid and CHIP Provisions

Coverage of COVID-19 vaccines and treatment under Medicaid and CHIP:

Requires Medicaid and CHIP coverage of COVID-19 vaccines and treatment without cost sharing for all eligible enrollees;
Increases federal medical assistance percentage (FMAP) to 100 percent for vaccine administration for one year after the end of the public health emergency (PHE); and
Provides an option for states to provide coverage of COVID-19 vaccines and treatment without cost sharing for uninsured individuals at 100 percent FMAP.

Option to provide additional Medicaid and CHIP postpartum coverage:

Allows states to extend Medicaid or CHIP coverage for 12 months after childbirth. (This option would be available for seven years).

Enhanced FMAP for mobile crisis intervention services:

State option would provide Medicaid coverage for qualifying community-based mobile crisis intervention services.
Provides 85 percent FMAP for these services. (This option would be available for five years.)

Temporary FMAP increase to incentivize Medicaid expansion:

Provides 5 percentage point FMAP increase to states’ base FMAP rates for eight calendar quarters to states that opt to implement the Affordable Care Act’s Medicaid expansion after enactment of the American Rescue Plan. (This increase is in addition to the temporary 6.2 percentage-point FMAP increase available during the PHE provided by the Families First Coronavirus Response Act)
FMAP increase applies to all Medicaid eligibility groups except the expansion group. Newly expanding states would receive the current 90 percent FMAP provided for the expansion group.

Temporary extension of 100 percent FMAP for care provided at Urban Indian Organizations and Native Hawaiian Health Care Systems:

Provides 100 percent FMAP for eight calendar quarters for services provided at Urban Indian Health Programs or the Native Hawaiian Health Care System to Medicaid enrollees.

Sunset of Medicaid Drug Rebate Limit:

Beginning in calendar year 2023, this provision would eliminate the cap on Medicaid drug rebates.

Temporary enhanced FMAP for home- and community-based services:

Provides 7.35 percentage-point FMAP increase for one year to help states implement improvements to Medicaid home- and community-based services.

Creation of state strike teams for nursing facilities:

Provides $250 million to the US Department of Health and Human Services for states to create strike teams to help nursing facilities manage COVID-19 outbreaks.

Key Private Market Coverage Provisions

Support for continuation coverage through COBRA:

Provides federal funding so that individuals would only have to pay 15 percent of their premiums toward COBRA coverage. COBRA allows individuals who have experienced job loss to continue enrollment in their employer-sponsored health insurance plan for a period of up to 36 months. Normally, individuals pay 100 percent of COBRA premiums. Federal funding will be available through Sept. 30, 2021.

Requires employers to provide updated information to qualifying employees about the program and be prepared to expedite review for any employees who are denied premium assistance.

Enhanced tax credits to purchase coverage through health insurance marketplaces:

Provides a two-year enhancement to premium tax credits (PTCs) available to eligible individuals who qualify to purchase coverage through health insurance marketplaces. The enhancements both increase the amount of PTCs available at all income levels and eliminate the 400 percent earnings (of federal poverty level – FPL) limit to qualify for PTCs.
Funding would cap monthly premiums at no more than 8.5 percent of an individual’s income.
The PTC enhancements would be available for the 2021 and 2022 plan years. Individuals who are currently enrolled in marketplace coverage would be eligible for rebates to cover expenditures already made toward 2021 coverage.
Disregards income above 133 percent of FPL for purposes of calculating eligibility for PTCs for any individual who receives unemployment compensation in 2021.
For more information about these proposals, read the February, 2021 National Academy for State Health Policy (NASHP) blog, Congressional Proposals Could Improve Coverage Affordability and Access for Millions.

NASHP will follow the American Rescue Plan Act as it moves through Congress and will continue to share information on provisions that are critical to states.

The State of the States: Amid the Pandemic, Governors Tackle Health, Social, and Economic Issues

March 1, 2021/in Policy Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Eligibility and Enrollment, Equity, Health Coverage and Access, Health Equity, Housing and Health, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Allie Atkeson, Anita Cardwell, Rebecca Cooper, Gia Gould and Elinor Higgins

Governors use their annual state of the state addresses to showcase recent successes and define their policy priorities for the year ahead. By late February, 45 governors had delivered speeches outlining plans to address a wide range of health and related issues in the coming months. All mentioned their states’ responses to COVID-19, frequently praising frontline responders and public health agencies and applauding their states’ agile interagency actions to address the pandemic.

Echoing their 2020 health care and social determinant priorities, many governors continued to address social drivers of health. In 2021, they again prioritized education, livable wages, and justice – all areas that have been exacerbated by the pandemic. Meanwhile, topics such as prescription drug costs, Medicaid expansion, and access to affordable and healthy food, while important, did not dominate the governors’ narratives this year.

View a chart highlighting governors’ goals on a variety of health-related policies here.

However, the issues governors addressed do not exist in silos. Many of these important topics, including equity, broadband, mental health, and justice, are themes woven throughout their addresses. Below are highlights of the key themes that governors raised.

COVID-19 Recovery

Every governor framed his or her state of the state address through the lens of COVID-19. Of those, 34 governors discussed specific plans for COVID-19 recovery. Twenty-seven focused on plans for expedient and equitable vaccine distribution and 11 governors discussed plans for community recovery.

Governors emphasized the importance of getting doses into arms quickly while prioritizing an equitable distribution – they highlighted state plans to build pop-up and mass vaccination clinics and deploy their National Guard units to aid in vaccination efforts. Several governors also highlighted innovative plans for community recovery both during and after the public health emergency ends. For example, Gov. Andrew Cuomo of New York announced his plan to build a public health corps to facilitate vaccination operations and share learnings and best practices to ensure New York is better prepared for future crises.

Governors also highlighted the importance of partnerships during the pandemic – between a state’s executive and legislative branches to pass emergency relief bills, as well as collaboration with other states to share workforce and supplies, such as the Northeast partnership between Connecticut, Rhode Island, Massachusetts, New Jersey, and New York.

Education

Forty-one governors discussed education in their state of the state speeches — up from 34 last year. It is well documented that individuals with more and better education experience improved health outcomes, and Pennsylvania Gov. Tom Wolf identified education as a critical social determinant of health, saying “universal high-quality education leads to healthier people and healthier communities.”

The majority of governors addressed the impact of the COVID-19 pandemic on children, educators, and families. Fourteen governors underscored the importance of fully funding K-12 schools despite the tight budgets that states are facing this year and 11 governors emphasized the importance of safely opening schools. Governors proposed a variety of approaches to encourage schools to reopen so that children could get back to learning in-person:

Arizona Gov. Doug Ducey proposed tying school funding to in-person learning as a way to incentivize schools to re-open their doors.
Massachusetts Gov. Charlie Baker said his team has been “working with a number of lab partners to develop a weekly COVID testing program for kids, teachers and staff.”
Nevada Gov. Steve Sisolak said that getting back to the classroom was the reason his state had “prioritize[d] our educators for vaccinations.”

Fifteen governors expressed support for expanded early childhood education programs, pre-kindergarten options, and improved childcare for young children. Participation in early childhood education programs has been linked to better health, higher educational achievement, and higher socioeconomic status in adulthood. But this year, two governors were also promoting it as a necessary childcare option for working parents, particularly mothers, who have had to leave the workforce to take care of children during the pandemic.

Recognizing the contributions that teachers have made throughout the pandemic was also a recurring theme. Fifteen governors proposed additional compensation for teachers through raises, bonuses, or increased pensions. Though some of these pay increases are aimed at improving teacher recruitment and retention, several governors framed them as a way to acknowledge the additional job challenges presented by COVID-19. Alabama Gov. Kay Ivey, for example, proposed a budget that included “a 2 percent pay increase as a way to express our state’s gratitude to our teachers who rose to the challenge during an unprecedented time for our state.”

In addition to acknowledging the challenges of the past year, governors also emphasized the variety of supports that children and families would need to recover from the pandemic. Ten governors proposed new college scholarships to alleviate financial stress for students and families, five introduced plans to increase support for low-income students and English-language learners, and four discussed the need for increased mental health supports as students return to school.

Broadband

Thirty governors discussed broadband and the internet access during their state of the state addresses, up from 16 last year. The issue of broadband and internet access became a significant issue during the pandemic, especially as it related to equity in accessing on-line education and telehealth services. Maine Gov. Janet Mills noted that, “high-speed internet is as fundamental as electricity, health, and water. It is the primary way of connecting with others in the 21st century.” Though the digital divide existed prior to the COVID-19 pandemic, the public health emergency highlighted the importance of access to reliable Wifi and exacerbated existing disparities. Seven governors specifically commented on the need to reduce the digital divide, with New Jersey Gov. Phil Murphy commenting on the state’s progress from 2020, noting that in the past year it had worked to close the digital divide and today, 95 percent of students have the tools they need, and the state is working to close the gap to zero.

Thirteen governors also connected reliable broadband to education. Connecticut Gov. Ned Lamont noted how COVID-19 revealed that, “…too many students are left on the wrong side of the digital divide that exacerbates the achievement gap. Computers, internet access, and broadband – these are the tools essential to students’ success during COVID and for the foreseeable future.” At least 10 governors noted their fiscal support to ensure equitable access to broadband has increased across the state. Idaho Gov. Brad Little reiterated that for children to have a future, they need equal access to education. He spoke about how Idaho could benefit for years from a $50 million investment in broadband infrastructure, to support remote working and learning, especially in rural Idaho.

Eight governors also cited the urban/rural divide in broadband access and shared plans to expand broadband in rural areas. Oregon Gov. Kate Brown’s budget proposal would invest over $100 million in broadband expansion statewide, focusing specifically to provide access to rural communities that have been disproportionately impacted during the pandemic. Wisconsin Gov. Tony Evers noted that Wisconsin ranked 36th in the country for accessibility in rural areas and declared 2021 the “Year of Broadband Access.” His 2021-23 biennial budget proposes to invest around $200 million into broadband — nearly five-times the amount invested in the past three budget cycles combined.

Jobs, Livable Wages, and Unemployment Insurance

A total of 28 governors spoke about employment-related issues, focusing primarily on local economic growth efforts and workforce development to help connect individuals to higher-paying jobs. A few governors also commented on how their states’ unemployment systems were strained to capacity due to pandemic-related need.

Many governors mentioned planned investments in job training initiatives. Gov. Steve Sisolak commented on the creation of the Nevada Job Force that would engage leading businesses to fund and develop employment training programs, and also mentioned plans to establish a Remote Work Resource Center to connect individuals to job opportunities in other regions. Montana’s governor indicated that the current budget allocates funds for trades education by offering up to 1,000 scholarships a year and providing businesses with a 50 percent tax credit if they have employees who participate in the program. South Carolina’s Gov. McMaster proposed directing $60 million towards job skills training for high-demand manufacturing jobs and another $37 million for workforce scholarships and grants at technical colleges. Indiana’s governor advocated for continued investment in successful existing workforce development programs that have helped many individuals complete post-secondary education and obtain higher-paying employment.

In recognition of pandemic-caused job loss and the greater number of individuals relying on unemployment insurance (UI) who sometimes had difficulty accessing these benefits, governors in Illinois, Kansas, Wisconsin pledged to invest resources into UI system improvements. Governors in Delaware, Illinois, Kansas, Maryland, Tennessee stressed the importance of continuing to support small businesses as they begin to rebuild post-pandemic. Georgia’s governor commented that the state should promote “…job creation from those industries that are critical to health care and building on Georgia’s momentum to become a leader in all sectors of the health care industry.”

Environmental Actions

Twenty-three governors addressed environmental issues — down from 30 in 2020. Only Gov. Jay Inslee of Washington drew the explicit connection between the changing climate and the emergence of novel diseases like COVID-19, while most governors focused on the economic opportunity of investing in clean and alternative energy. Among governors’ top priorities was improving access to clean water:

Gov. John Carney of Delaware: “We’ll again propose a $50 million investment in a new Clean Water Trust Fund. We will make sure that all Delaware families have access to clean drinking water. And we will place a special focus on those hard-to-serve families across our state.”
Gov. Gretchen Whitmer of Michigan: “Last year, I announced the MI Clean Water Plan, a $500 million investment in Michigan’s water infrastructure. Direct dollars to communities for safe, clean water to residents. And it supports over 7,500 Michigan jobs. It’s time for the legislature to pass these bills so we can start rebuilding Michigan’s water infrastructure. I will keep working so every family in Michigan has clean, safe water.”

Behavioral Health

Twenty-two governors mentioned behavioral health in their state of the state speeches, including the effect of COVID-19 on mental health and substance use disorder. Arizona Gov. Doug Ducey identified impacts of COVID-19 “beyond the disease itself… opioid abuse, alcoholism, addiction, mental health issues, the sheer loneliness of isolation, suicide: there has been no daily count of these human costs, but they are real and they are devastating.”

Nine governors mentioned significant investments in their state’s behavioral health care infrastructure and services and eight governors addressed substance use disorder (SUD) prevention and treatment as a priority.

Alabama Gov. Kay Ivey said the state is investing “$46 million investment to expand 96 beds at the Taylor Hardin facility in Tuscaloosa and another $6 million for an additional crisis diversion center.”
In Montana, Gov. Greg Gianforte plans to use tax revenues from the sale of recreational marijuana, state and federal funding to create a $23.5 million fund to provide a continuum of SUD services.
Missouri Gov. Michael Parson plans to invest in their workforce with “$20 million for 50 new community mental health and substance use disorder advocates and six new crisis stabilizations centers across the state.”
Maine Gov. Janet Mills announced, “$7.5 million for mental health and substance use disorder, including community mental health and $2 million for our OPTIONS Initiative to dispatch mobile response teams to those communities that have high rates of drug overdoses — something that is more important than ever, given the increase in overdose deaths in Maine and the rest of the nation during the pandemic.”

Ten governors emphasized the impact of school closures on children’s mental health and made commitments to addressing the problem. Tennessee Gov. Bill Lee’s budget includes “$6.5 million in our mental health safety net which will be focused on providing services for school-aged children struggling with mental health issues.” South Carolina Gov. Henry McMaster’s budget includes a proposal so that all children in school have access to a mental health counselor.

Governors identified technology as an important tool in the delivery of behavioral health services. Four governors identified telehealth to increase access to behavioral health services and two governors mentioned support lines for their residents.

Colorado Gov. Jared Polis, discussing telehealth stated, “….which isn’t just a useful innovation in a time of social distancing. It’s a convenient tool for folks who want to receive care from the comfort of their own homes, and it’s literally a lifesaver for many Coloradans in rural areas who may live far away from doctors and clinics and hospitals.”

In her state of the state address, New Mexico Gov. Michelle Lujan Grisham announced, “the nation’s first text-only abuse and neglect hotline for New Mexico children, providing them an outlet that research has shown they may be more comfortable using.”

Legal System Reform

In 2020, the murders of George Floyd and Breonna Taylor highlighted the need for criminal justice reform. This year, 22 governors referenced justice in their state of the state speeches, more than in 2020. Criminal system reform is a key health issue as corrections-involved individuals have high rates of chronic conditions and poor mental health outcomes.

In addition to legal system reform, governors addressed infrastructure investments in correctional facilities, expanding re-entry programs and treatment courts and the death penalty. Governors in four states, Connecticut, Kentucky, New Jersey and Virginia, have plans to legalize marijuana.

Ten governors mentioned reforming their state’s criminal legal system through a variety of policies, including banning chokeholds, limiting no-knock warrants, and eliminating mandatory minimums for nonviolent crimes. Virginia Gov. Ralph Northam addressed expungement in his speech stating, “rooting out inequities includes expunging the records of people who were convicted of this and certain other crimes in the past.”

Governors in Alabama, North Dakota and Tennessee addressed re-entry programs. Tennessee Gov. Bill Lee’s budget includes “$4.7 million for additional day reporting centers and evidenced-based programming for community supervision. This approach ensures that re-entry to society is done in the most safe and effective way possible for those who were formerly incarcerated.” Montana Gov. Greg Gianforte’s budget includes an investment in [drug] treatment courts. He stated, “…we must prioritize and invest in treatment courts. Treatment courts work. They reduce recidivism. They reduce drug use. They increase public safety. And they are much more cost effective than incarceration.”

Health and Social Equity

COVID-19 has laid bare health and social inequities, and 2021 state of the state addresses shows that achieving equity is a bipartisan goal – 21 governors discussed strategies to work towards equity. Reducing racial and ethnic disparities is of great interest to governors, several discussed racism and racial injustice, describing how communities of color, including tribal communities, were disproportionately impacted by COVID-19, and they expressed their commitment to improvement. To address this, two governors announced new positions dedicated to increasing equity:

Delaware Gov. John Carney created a new position, Director of Statewide Equity Initiatives, designed to make sure those in state government are leading with equity. He noted, “…We’ve also worked hard to build a cabinet that looks like Delaware. We created the position of Chief Diversity Officer to focus on recruitment and retention of a diverse state workforce.”
Indiana Gov. Eric Holcomb announced, “We’ll get our state’s first-ever cabinet-level Chief Equity, Inclusion, and Opportunity Officer to improve and report on diversity outcomes across state government.” He also announced the state’s plan to launch a diversity data dashboard.

Equity was also woven into governors’ speeches around various topics. Eleven governors addressed equity in access to jobs and health care, seven governors addressed the impact of inequities and education, five governors discussed the intersection of equity and women and children’s health – including New Jersey and Indiana’s governors announcing programs to reduce infant and maternal mortality. Seven governors discussed increasing equity in broadband and internet access and closing the digital divide:

Hawaii Gov. David Ige announced that his legislative package includes a bill to create a Broadband and Digital Equity Office. This office will help enable the state to identify and secure Hawaii’s share of federal funds to enhance broadband infrastructure and digital equity programs.

New Mexico Gov. Michelle Lujan Grisham stated, “We will enact an equity-first budget for public education, ensuring money reaches students and schools in proportion to the socioeconomic needs of families in the community, laying the path to a public education system that truly delivers for students now and a hundred years from now, no matter their zip code, their family circumstances or the color of their skin.”

Medicaid, Coverage and Access to Care

While all states have experienced Medicaid enrollment growth due to the pandemic’s economic effects, only nine governors explicitly mentioned Medicaid in their speeches. Only Nevada’s Gov. Steve Sisolak commented on the program’s increased enrollment, and he indicated that the upcoming budget would reverse provider rate reductions due to revenues surpassing initial projections. Governors in Missouri and Oklahoma mentioned their states’ plans to implement Medicaid expansion in response to ballot initiatives that were passed last year, and as in the prior year, Gov. Laura Kelly in Kansas again advocated for the state to take up expansion.

Tennessee’s governor highlighted the state’s recently approved Medicaid block grant waiver and also noted planned investments in the health care safety net and extensions of Medicaid coverage for adopted youth and during the postpartum period. Oklahoma’s Gov. Kevin Stitt mentioned the state’s move toward Medicaid managed care as “the best way forward” and Indiana’s governor commented that implementing a managed long-term services and supports program within Medicaid would help families more easily navigate care options.

The broader topic of health coverage and access to care was cited more frequently than Medicaid, with 17 governors commenting on this issue. Most commonly, governors focused on the crucial role that telehealth has served over the past year in maintaining access to both health and behavioral health services. Governors in Hawaii, Idaho, Indiana, Iowa, Kentucky, Missouri, New York, and Texas advocated that expanded telehealth capacity should be sustained and strengthened after the pandemic, and Gov. Charlie Baker commented on Massachusetts’ recent actions to make its telehealth changes permanent.

Colorado’s Gov. Jared Polis noted plans to once again try to pursue a public option to expand coverage, commenting: “And we look forward to adding an affordable Colorado Option that will give Coloradans — especially in rural communities — more choice and savings, when it comes to selecting a health care plan.” Gov. Andrew Cuomo proposed expanding access to affordable coverage by eliminating premiums for 400,000 low-income New Yorkers, and New Mexico’s Gov. Michelle Lujan Grisham mentioned plans to create a Healthcare Affordability Fund that could potentially provide health coverage to 23,000 uninsured New Mexicans within a year.

Housing and Homelessness

Sixteen governors addressed housing or homelessness in their 2021 speeches. The COVID-19 pandemic has exacerbated the United States’ existing affordable housing crisis. Additionally, people experiencing homelessness are at an increased risk of contracting COVID-19. The CARES Act Emergency Rental Assistance Program allocated funding to states for rent and mortgage relief.

Six governors discussed their eviction prevention programs and eviction moratoriums. New Jersey Gov. Chris Murphy commented “as the pandemic literally hit people where they live, we instituted strong prohibitions against evictions and utility cutoffs to protect our families. We provided rental assistance to nearly 20,000 individuals and families facing immediate challenges.” In addition to eviction prevention, Illinois Gov. J.B. Pritzker “dedicated a record $275 million to help pay utility bills for those suffering COVID-related income loss. Homelessness is never acceptable, but in a pandemic it’s downright barbaric.” Two Governors, New York Gov. Andrew Cuomo and Oregon Gov. Kate Brown addressed homelessness, Gov. Andrew Cuomo stating, “homeless shelters must be available, safe and secure. It’s not just our moral obligation, it is our legal obligation.”

Eight governors addressed expanding access to affordable housing. Virginia Gov. Ralph Northam stated, “it’s also time to help people by taking more action on affordable housing. We have made record investments in the Virginia Housing Trust Fund that helps make more affordable housing available.” Oregon Gov. Kate Brown’s budget includes a $250 million dollar investment in affordable housing, homelessness prevention and rental assistance. Governors also identified strategies to address property taxes, exclusionary zoning and the cost of land as barriers for affordable housing.

Health Care Costs

Eleven governors addressed health care cost and affordability — down significantly from 2020, when 21 governors addressed the issue. This year, governors focused on lowering health costs for consumers affected by the economic impact of the pandemic. Several introduced strategies to lower consumers’ premium costs:

Gov. Andrew Cuomo of New York proposed the elimination of health care premiums for more than 400,000 low-income New Yorkers.

Gov. Phil Scott of Vermont directed his Department of Health Insurance Regulation to determine whether Vermonters are eligible for premium rebates due to low health care utilization during the pandemic.

Gov. Phil Murphy of New Jersey highlighted the state’s successful launch of its State-Based Marketplace, which has lowered premiums for hundreds of thousands of New Jersey residents.

Gov. Michelle Lujan Grisham of New Mexico mentioned plans for a Healthcare Affordability Fund that would dedicate resources to lowering health insurance premiums and protect consumers from burdensome out-of-pocket costs.

Governors in Connecticut, Oregon, Vermont, and Utah seek to curb their state’s health care spending through cost and/or quality benchmarks. Vermont Gov. Phil Scott proposed setting a cap on annual price increases for health costs. In New Jersey and Utah, governors expressed their commitment to improving price transparency and data sharing, emphasizing the importance of building resources to help consumers better understand health care costs.

Only four governors addressed rising prescription drug prices – a significant decrease from last year when 12 governors addressed the issue.

Health Care Workforce

This year, eight governors addressed health care workforce issues, with most proposing solutions to meet the increasing demand for providers during the pandemic. Governors in three states proposed educational initiatives to bolster health care workforce development, including a grant program introduced by Gov. Mike Parson of Missouri to fund new health care associate degree programs at community colleges. Gov. Pete Ricketts of Nebraska shared plans to expand the health care workforce by formalizing flexibilities implemented during the pandemic that allow licensed health care professionals from other states to practice in Nebraska, and governors from Kentucky, Idaho, and Nevada committed increased funds to address provider shortages. Two governors remarked on the importance of their volunteer workforce, with Gov. Ralph Northam of Virginia calling on retired nurses and doctors to contribute to the COVID-19 vaccination effort.

Other Health-Related Issues

A sampling of other health-related topics that governors mentioned included:

Transportation: Twelve governors talked about the need for modernized and healthy transportation systems. Indiana’s governor promoted his plan to convert old train tracks into hiking and biking trails, and Colorado’s governor made the connection between multi-modal transit options, electrification of transportation, and cleaner air.
Child Welfare: Six governors discussed the child welfare system, highlighting progress and the need for more reform. Arkansas’ governor made a commitment to preventing abuse and protecting vulnerable children in the foster care system. Tennessee’s governor announced an extension of Medicaid coverage for foster children that would ensure a more seamless transition to family’s health plans during the adoption process.
Violence prevention: Arkansas’ governor urged state legislators to pass hate crimes legislation, Georgia’s governor highlighted the need to address sex trafficking, and Alaska’s Gov. Mike Dunleavy indicated that his budget fully funds the state’s domestic violence and sexual assault programs and includes $7 million to help prosecute individuals who commit sexual assault and domestic violence crimes. Montana Gov. Greg Gianforte addressed the crisis of missing and murdered indigenous individuals, who make up 7 percent of the population but account for 26 percent of missing persons.
Medical supplies: New York’s Gov. Andrew Cuomo commented on the state’s medical supply chain being too reliant on overseas manufacturing and noted plans to incentivize state businesses to produce medical supplies.
Food: Eight governors discussed food security, production, and distribution. Several governors commended the additional food security supports that were put in place to meet families’ needs during the pandemic. Oregon’s governor talked about new funding for wrap-around services in schools, including nutrition support.
Wellness promotion: Oklahoma’s governor said that state leaders should address the high rates of obesity, diabetes, and heart disease among state residents.

Despite the significant challenges of addressing COVID-19, states are continuing to pursue innovative policies and initiatives to address a wide range of health and health-related issues, with many proposals developed directly in response to disparities highlighted by the pandemic. The National Academy for State Health Policy will continue to track many of these topics in the coming months.

2021 State of the States: Amid the Pandemic, Governors Tackle Health, Social, and Economic Issues

March 1, 2021/in Policy Charts, Maps Chronic Disease Prevention and Management, Consumer Affordability, COVID-19, Eligibility and Enrollment, Equity, Health Coverage and Access, Health Equity, Health System Costs, Housing and Health, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by NASHP Staff

How States Improve Housing Stability through Medicaid Managed Care Contracts

February 19, 2021/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

In 2019, more than 500,000 individuals experienced homelessness and nearly 20 million renters spent 30 percent or more of their income on housing. These numbers are increasing as the COVID-19 pandemic exacerbates housing insecurity for people of color and low-wage workers. To improve housing stability – a critical social determinant of health (SDOH) – states are using Medicaid managed care contracts to encourage health plans to support members’ housing-related needs and promote coordination between housing providers and health plans.

Background

Housing status is a key social determinant of health. Many individuals experiencing homelessness suffer from diabetes, heart disease, and HIV/AIDS at rates that are up to six times higher than the general population, and are at increased risk for contracting COVID-19. Rates of mental illness and substance use disorders are also significantly higher among individuals experiencing homelessness.

Many individuals experiencing or at risk of homelessness qualify for Medicaid. Medicaid can be a valuable resource for helping individuals facing housing insecurity, and research shows that investing in housing can save states money and improve health. One study found that hospitalization, emergency room use, and total expenditures for individuals experiencing homelessness in Massachusetts were 3.8-times higher than for the average Medicaid recipient.

Increasingly, state Medicaid agencies are focusing on addressing housing-related needs of their enrollees through their managed care contracts.

The National Academy for State Health Policy (NASHP) recently completed its three-year Health and Housing institute. Read its final report, Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives, to learn how Illinois, Louisiana, New York, Oregon, and Texas improved their respective health through housing initiatives.

How States Use Medicaid Managed Care Contracts to Address Housing Needs

While Medicaid managed care contract language varies significantly between states, there are some similarities in states’ approaches to addressing Medicaid enrollees’ housing needs, including these managed care organization (MCO) contractual requirements:

Screen enrollees for housing-related needs;
Hire designated housing coordinators; and
Ensure the coordination of care between housing providers or agencies and Medicaid programs.

States working to address housing insecurity and homelessness among Medicaid enrollees, or states that already require plans to focus on SDOH more broadly but wish to tailor initiatives specifically towards improving housing status, can adopt some of the contractual language and initiatives described below.

Screening for Housing Insecurity

According to NASHP’s scan of states’ Medicaid managed care contracts, 16 states (of 38 with publicly available contracts or requests for proposals) require contractors to conduct routine screenings for certain SDOH. Of the 16 states, 14 require their managed care plans to screen members about their housing needs during these assessments. These screenings can occur at any interval from annually to quarterly, with some states specifying that individuals who qualify as high-needs members should be screened more frequently. In New Hampshire, community mental health programs that contract with the state’s Medicaid program are required to conduct quarterly assessments and document all members’ housing status. In Pennsylvania, providers must complete an SDOH assessment that focuses on housing security, among other things, at least annually and more often depending on the individual’s risk level.

While some states require health plans to screen all enrollees, others only require screenings for certain populations. For example, Minnesota’s Medicaid MCO requires outreach and screening for members who have been to the emergency department for services three or more times within four consecutive months. In Alabama, the maternity psychosocial assessment includes questions related to homelessness.

Screening for housing status in order to identify members experiencing housing insecurity or homelessness is an important first step in addressing housing needs. However, in the absence of mechanisms to connect individuals to community resources that can help them find appropriate housing assistance, the impact of SDOH screenings is limited.

Hiring Housing Coordinators

According to NASHP’s analysis, seven state Medicaid MCOs identify a designated, full-time employee exclusively responsible for addressing enrollees’ housing needs – Arizona, Kansas, Louisiana, New Hampshire, New Jersey, New Mexico, and North Carolina. Other states, including Delaware and Pennsylvania, require their plans to hire more broadly defined care coordinators or SDOH specialists. They work on housing as part of their jobs, but are also responsible for addressing other member needs, such as employment, transportation, and education.

Through its contract with Kansas Medicaid, United Healthcare employs a housing navigator, a position added in 2016. The housing navigator develops partnerships statewide to identify resources for providing housing supports – including vouchers, prevention services, public housing, and homeless service agencies – and to help members locate housing. United Healthcare’s housing navigator has assisted more than 200 Medicaid members with housing needs.

The Louisiana MCO contract requires the plan to hire a permanent supportive housing program liaison who works with the Louisiana Department of Health to help implement the PSH program deliverables, which include providing affordable housing and tenancy supports. While hiring housing navigators or specialists requires MCOs to invest financial resources, onboarding navigators to help connect members directly to housing services and supports has been shown to be one effective way to address Medicaid enrollees housing-related needs, especially those identified during SDOH screenings.

Partnering with Housing Providers and Agencies

State housing agencies and local housing providers are also valuable resources for improving both the health and housing needs of individuals. Rather than building new systems, managed care plans can address housing insecurity among members by partnering with existing housing services and working to eliminate siloes between health and housing agencies.

For example, in New Mexico, health plans are required to contract with a federally qualified health center that specializes in providing health care for populations experiencing homelessness. Similarly, in New York, health plans are required to coordinate care with Health Care for the Homeless providers. In Oregon, Coordinated Care Organizations – the state’s Medicaid accountable care organizations – have contracted with community-based organizations to provide housing supports and helped develop a medical respite program to house individuals experiencing homelessness following an inpatient hospital stay.

Initial data from New York’s pilot partnership project between Medicaid MCOs and housing providers to reach individuals experiencing homelessness who are high utilizers of Medicaid services showed a 46 percent reduction in emergency room (ER) visits, a 47 percent decrease in Medicaid costs, and a 99 percent reduction in ER costs for participants.

Some state Medicaid contracts also identify opportunities for MCOs to support housing initiatives run by state or federal housing agencies. In Texas, the Medicaid MCO service coordinator must work with staff from their Section 811 Project Rental Assistance program, a federal program that helps provide supportive housing for individuals with disabilities, to coordinate care for Texans receiving Section 811 services and those leaving nursing facilities. This helps integrate health and housing services for individuals previously identified as having housing needs. In Louisiana, the state housing authority and the Department of Health co-manage the permanent supportive housing (PSH) program. The Louisiana MCO contract outlines a number of ways that MCOs are required to support the PSH program, including:

Provide outreach to members who qualify for PSH;
Help members apply for PSH;
Ensure timely prior authorization for PSH tenancy and pre-tenancy supports;
Refer members approved for PSH to relevant providers; and
Work with PSH program management to ensure an adequate and qualified network of PSH program staff and service providers.

The MCO is also required to contract directly with housing providers approved by the state to provide tenancy and pre-tenancy supports to members participating in the PSH program. One analysis of Louisiana Medicaid recipients pre- and post-PSH showed a 26 percent reduction in emergency room visits, a 12 percent reduction in hospitalizations, and an increased use of behavioral health services among participants. Through partnerships with PSH programs, MCOs can improve integration of health and housing services for members and expand the reach of housing programs by helping to identify Medicaid enrollees in need of housing and connect them directly to resources.

Creative Financing

State Medicaid managed care contracts employ creative ways to use Medicaid funding to support efforts to address housing insecurity among enrollees. Although Medicaid cannot directly fund housing, there are many other strategies to effectively invest in housing services. Oregon’s Coordinated Care Organizations (CCOs) are required to spend a portion of their profits or reserves on health-related services, and specifically on housing supports. Starting January 2021, CCOs are also required to submit annual spending plans to the state, which include the CCO’s spending priorities related to addressing SDOH and health equity, and how they align with the state’s housing-related priorities. In Kansas, the state’s MCO request for proposal calls for alternative payment strategies to incentivize warm handoff transitions for individuals moving from institutions into community-based programs and services.

In Massachusetts, the managed care contract mentions the Social Innovation Financing for Chronic Homelessness Population Program (SIF), a Pay For Success (PFS) initiative that finances PSH. Through the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), Medicaid managed care entities fund support services for PSH tenants in the PFS program. As of October 2020, 860 members have enrolled in CSPECH. Together with the PFS program, CSPECH has improved housing retention, decreased emergency room stays, and saved millions in costs. While the current budget climate arising from the COVID-19 pandemic makes adopting new funding strategies difficult, investing health plan dollars in housing services can not only improve members’ housing status, but also decrease Medicaid spending down the line.

Pilot Programs

In addition to established methods, such as screening for housing needs and partnering with housing service providers, some states are using their managed care plans to launch new initiatives to address their Medicaid enrollees’ housing needs. In Florida, MCOs are participating in a voluntary pilot program to provide behavioral health services and supportive housing assistance directly to Medicaid enrollees who are homeless or at risk of homelessness and who also experiencing either serious mental illness or substance use disorder. The North Carolina managed care contract provides for an Enhanced Case Management Pilot program in up to four areas of the state. MCOs in each area work to determine the most effective, evidence-based interventions to address four priority domains, which include housing. The program also requires each program to evaluate the effect of the interventions on health care costs and outcomes. There is no “one-size-fits-all” approach to addressing housing, but piloting programs like these, or creative financing solutions like those mentioned above, can help MCOs determine which methods are best for reaching housing-insecure members in their state, while also improving health outcomes and decreasing costs.

Conclusion

As efforts to address SDOH become increasingly common among Medicaid managed care plans, many states are narrowing their focus to address housing insecurity and homelessness specifically. By working to identify enrollees’ housing needs and directly connect them to housing and supportive services, health plans can improve housing stability, which in turn improves health outcomes and decreases costs.

During the COVID-19 pandemic, states face budget challenges while their Medicaid managed care plans may experience financial gains from a decline in demand for physical health services. This leaves health plans in a unique position to invest new resources upfront in housing-related services. In 2020, many insurers reported large profits, in part due to the decline in non-COVID-19-related hospital admissions. Medical Loss Ratio rules, however, limit the amount insurers can keep for profit or overhead costs – health plans must either issue rebates or spend more on health-related services, which presents an opportunity to use these additional funds to address housing insecurity and homelessness among enrollees. And, by requiring health plans to indirectly invest in housing by hiring housing coordinators, partnering with existing housing agencies who are already immersed in the work, financing housing-related services, or by piloting new, creative solutions, states can take the lead in guiding Medicaid managed care plans’ work.

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 U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

State Maternal Mortality Review Committee Membership and Recommendations

February 18, 2021/in Policy Charts, Featured News Home, Maps Health Equity, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Social Determinants of Health /by Taylor Platt and Eddy Fernandez

States Identify and Address COVID-19 Vaccine Disparities through Targeted Rollout and Outreach

February 8, 2021/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Health Equity, Population Health, Social Determinants of Health, Vaccines /by Rebecca Cooper, Ariella Levisohn and Jill Rosenthal

As states rapidly work to get COVID-19 vaccines into arms as quickly as possible as viral variants spread, state officials know vaccine rollout plans must focus on equitable distribution to communities of color, especially Black and Latinx communities that have experienced disproportionately high infection rates, hospitalizations, and deaths. However, early data suggests that these populations are receiving vaccines at lower rates than White Americans.

As President Biden highlights his administration’s commitment to equity, officials from a cross section of states told the National Academy for State Health Policy (NASHP) how they are working to simultaneously build and strengthen systems to track and address disparities in COVID-19 vaccine administration.

The Biden Administration’s National Strategy for the COVID-19 Response emphasizes equity in vaccine distribution to “protect those most at risk and advance equity, including across racial/ethnic and rural/urban lines.” This includes increasing data collection and reporting for high-risk groups, supporting communities most at risk of COVID-19, and ensuring equitable access to critical COVID-19 personal protective equipment, tests, therapies, and vaccines. These steps help achieve equity by identifying underserved communities, sending them extra vaccine supplies, improving public trust in the vaccine, and ensuring individuals are able to get vaccinated.

Recently, the Biden Administration announced it will begin shipping an additional 1 million vaccine doses each week to thousands of pharmacies across the country in an effort to improve equity and increase access to the vaccine.

Preliminary data highlights vaccine disparities:

As of Feb. 8, 2021, less than 3 percent of the US population had been vaccinated with both doses to date. Though data is limited and race and ethnicity are widely underreported, preliminary data does show racial disparities.

The US Centers for Disease Control and Prevention’s Feb. 1, 2021 Morbidity and Mortality Weekly Report noted that to date 60.4 percent of vaccine recipients were White and 39.6 percent were people of color.

However, only 50 percent of the 6.7 million doses administered through Jan. 14, 2021 documented the race and ethnicity data of vaccine recipients.

The available data highlights disparities in communities of color:

• 4 percent of vaccine recipients were Black (though Black people make up 12.2 percent of the population); and

• 5 percent self-reported as Hispanic/Latino (who make up 18.5 percent of the US population).

Pharmacies will be a critical venues for vaccine access, and this pharmacy distribution program is expected to build that capacity as the US Centers for Disease Control and Prevention (CDC) and state health directors work together to identity areas of need and ship vaccines to pharmacies in those areas, especially in the early days of the program when distribution is still curtailed by limited vaccine supplies. State officials told NASHP that the selection of pharmacies will be based on their ability to both reach the most vulnerable populations and also align with states’ current distribution phases and priority populations in their vaccination plans.

Pandemic responses have shown that federal leadership is key to success. The following examples highlight how state efforts to collect and analyze trends in race and ethnicity data, supported by strong directives from the White House and a centralized federal task force, can guide decision making and promote the implementation of concrete strategies to reduce disparities.

For more information on which states are tracking vaccination data by race and ethnicity, explore NASHP’s interactive map.

Tracking and Reporting Race and Ethnicity Data

One of the first steps to ensure equitable access to vaccines is having the data to determine where disparities exist. Forty-eight states and Washington, DC currently collect and share varying levels of vaccine data in publicly available data dashboards. Of these, 26 states and Washington, DC publicly display race and ethnicity data for individuals who have received their vaccines. States report the data slightly differently – which can result in different conclusions about their efforts. They are reporting either:

Total number of individuals vaccinated by race and ethnicity (for example, Florida and Pennsylvania);
Percentage of total individuals of each race or ethnicity in the state who have been vaccinated (North Dakota); or
Percent of total doses that have gone to individuals by each race and ethnicity (Indiana and North Carolina).

While these state trackers provide some insight into who is getting vaccinated, there are limitations in their data – a large percentage of race and ethnicity data is either missing or not reported. Nationwide, race and ethnicity data is missing for nearly half of those vaccinated, compared to age and gender data, which is reported 99.9 and 97 percent of the time, respectively. Even in states that collect and publicly report this data, some report over 50 percent of doses with “unknown” race and ethnicity. Providers will report “unknown” in the race and ethnicity fields either because the providers do not ask for the data, or because the recipients do not provide it. It is unclear why individuals are declining to provide their race and ethnicity, but some experts believe that some concerns may stem from a fear that their demographic data could be misused. For example, immigrants are concerned that getting the vaccine – or providing their data – may negatively affect their immigration status. However, the CDC said that vaccine data cannot be used for immigration enforcement, and that getting the COVID-19 vaccine will not be considered as part of the public charge inadmissibility rule.

Many states are working to improve their data collection and reporting. Some, such as Alabama, are collecting race and ethnicity data but have not yet made it public because it is incomplete. These states are working to collect complete and accurate data before publishing it. Most states that are reporting race and ethnicity data publicly do not require providers to include that information, citing a lack of express permission from the patient or concern that requirements might prevent providers from reporting vaccine doses at all.

Other states are imposing requirements to improve data. In North Carolina, Department of Health and Human Services Secretary Mandy Cohen pushed to make race and ethnicity a required field in the state’s COVID-19 vaccine registry. According to state officials, North Carolina emphasizes equity as a core value and conducts outreach and training with providers to emphasize the importance of race and ethnicity data. The availability of the data has enabled outreach strategies, such as partnerships with faith leaders.

While requiring providers to upload race and ethnicity data can add to administrative and logistical challenges, collecting the data is critical to ensuring that vaccine outreach and administration are targeted to the communities most in need. If large percentages of race and ethnicity data are missing, ensuring equity in distribution becomes much more difficult.

State Strategies to Reduce Disparities in Vaccination

Tracking disparities by identifying gaps in data is only the first step. In response to early data that showed disparities, states are taking action to address inequity by scheduling clinics in high-need areas, facilitating vaccination in high-priority zip codes, and tailoring communications to address vaccine hesitancy. President Biden’s plan to add to states’ allotments by sending vaccines directly to local pharmacies beginning Feb. 11, 2021 will also aid in the goal of an equitable distribution. Pharmacy partners were selected in part based on their ability to reach socially vulnerable populations, and the program will follow each state’s current eligibility requirements to ensure individuals, especially those in high-need areas, have access to the vaccine. States are also currently working to reduce disparities by using strategies to increase access to, and comfort level with, the vaccine.

Many states are using the CDC’s Social Vulnerability Index (SVI) to identify areas of high need where vaccine distribution efforts should be targeted. The SVI is a CDC tool that uses US census variables – including socioeconomic status, transportation access, housing status, and language – to rank areas in order to help public health officials prepare for and respond to emergency events. A high ranking indicates that an area may need more support for their emergency response – in this case vaccination distribution and administration.

Locating Clinics in High-Need Areas

Delivering vaccines to underserved communities is key and the new Federal Pharmacy Program helps address this goal. States and local health departments can use preliminary data to identify counties or jurisdictions with disparities and low rates of vaccination uptake to use to target their vaccination efforts.

Rick Palacio, the cochair of Colorado’s COVID-19 Vaccine Equity Taskforce, announced that one of the state’s goals is to hold pop-up vaccination clinics in half of the state’s top 50 census tracts containing low-density, low-income communities. Officials emphasized the importance of using data to determine under-vaccinated areas and tailor communication strategies to reach those residents. The state kicked off this plan by vaccinating more than 10,000 seniors at a mass vaccination event in Denver and plans to expand the initiative as it receives more doses.

Other examples of state efforts to identify and reach underserved areas include:

Rhode Island is using its hospitalization, death, and case data to target vaccine distribution by geography. Vaccines will be available in community clinics, pharmacies, and housing sites in communities that have been identified as high risk.
Illinois has had success by holding events scheduled by local health departments that reached out to discreet, hard-to-reach communities and invited them to register for a vaccine appointments.
Connecticut is closely tracking vaccine rollout in localities that rank high on the social vulnerability index.
After Washington, DC opened its vaccine registration portal to all individuals over the age of 65, data quickly showed that an outsized proportion of appointments was going to wealthier White residents. In response, health officials made more appointments available for residents in parts of the city that were currently securing the fewest vaccine appointments. The city also started making appointments for residents in these high-priority zip codes available a day before other eligible residents could register.
North Carolina has partnered with faith leaders to ensure communities of color and underserved communities have access to vaccinations at the state’s mass vaccination clinics, including releasing appointments to Black and Latinx church attendees before opening up registration to the general public.

States can also reduce transportation barriers to increase vaccination uptake and ensure transportation will not be a barrier for targeted populations to access the vaccine. North Carolina’s mass vaccination clinic location was chosen for its proximity to public transportation.

The Tennessee Department of Health (TDH) is expanding access to the COVID-19 vaccine by focusing on increasing vaccinations in rural and underserved areas. TDH partnered with pharmacies and community health clinics to add over 100 vaccination sites across the state, focusing on “hard-to-reach” areas, as identified in the state’s vaccination plan. Tennessee’s state plan indicated that 5 percent of the state’s allocation of COVID-19 vaccines are earmarked for use in targeted areas with vulnerable populations.

Additionally, at a February US House Energy and Commerce Oversight and Investigations Subcommittee hearing, Louisiana state officials cited a plan to create community mobile strike teams that will travel to areas that rank high on the social vulnerability index to administer vaccines. The strike teams will be staffed by the National Guard and funded by the Federal Emergency Management Administration, which reimburses states for 100 percent of costs associated with the National Guard’s COVID-19 relief efforts. A state official in Michigan also noted at this hearing that the increase in doses from the federal government will help advance equity, because those extra doses can be distributed directly to underserved areas and minority populations.

Tailoring Communication Strategies to Address Vaccine Hesitancy

While reporting and tracking vaccination data and removing logistical barriers are important strategies for identifying pockets of need, they alone are not sufficient to reduce disparities. A history of racism in the health care system has led to distrust by communities of color. Though the share of adults planning to get the COVID-19 vaccine has increased over the year, according to recent surveys White adults (53 percent) remain more likely than Black (35 percent) and Latinx (42 percent) individuals to want to be vaccinated as soon as possible. A survey last fall found that less than 20 percent of Black Americans trusted vaccine safety and efficacy. The survey also indicated that the best messengers to support vaccination in these communities are those living in their own communities, or their health care providers.

State officials and several members of the federal Advisory Committee on Immunization Practices (ACIP) mentioned that the desire to vaccinate quickly must be balanced with the need to reach vulnerable communities. State officials note that balancing speed and equity is one of the biggest challenges they face. Community input builds trust and assists in building effective and acceptable strategies. For example, Tennessee has an African American Health Care Clinician Workgroup, with working members from the NAACP, the Black Nursing Society, and other Black organizations, who are disseminating messaging on the importance of vaccinations and will ultimately help vaccinate Black communities. The Colorado Department of Health and Environment has released commercials in English and Spanish featuring Colorado health care workers who are people of color, promoting the message that vaccines are safe. West Virginia is funding faith-based community members and people of color to administer COVID-19 vaccines directly to communities of color, ascribing to the principle that having trusted, local figures helping with distribution will improve those communities’ confidence in the vaccine.

Conclusion

Federal and state governments are working to vaccinate residents as quickly as possible, while also working to ensure doses are equitably distributed. In light of reports of disparities in vaccination rates and in vaccination access among people of color and in rural communities, the Biden Administration is acting on its promise to ensure an equitable distribution, including their new strategy to ship extra doses to pharmacies in hard to reach areas. While distribution strategies vary across states and are continually tweaked to improve efficacy and equity, the emerging best practices:

Use data to track and identify under-vaccinated areas and populations;
Set up additional clinics in underserved areas and provide additional doses to these clinics;
Ensure transportation is available for patients to access the clinics; and
Partner with local agencies and community organizations to promote vaccine confidence.

Each of these components is necessary to ensure underserved communities and communities of color are interested in receiving vaccines and are able to access them.

This analysis 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 $200,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) 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

Oregon’s Community Care Organization 2.0 Fosters Community Partnerships to Address Social Determinants of Health

February 5, 2021/in Medicaid Managed Care Oregon Featured News Home, Reports Accountable Health, Health Equity, Housing and Health, Medicaid Managed Care, Population Health, Program Design, Quality and Measurement, Social Determinants of Health /by Neva Kaye

American Rescue Plan Could Significantly Enhance Health Insurance Coverage

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