A Case Study of the Virginia COVID-19 Equity Leadership Task Force and Health Equity Working Group
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This new case study is part of a learning network hosted by the National Governors Association, Duke-Margolis Center for Health Policy, and NASHP that convenes governor-appointed health equity COVID-19 task force leaders throughout the nation.
- The case study highlights efforts from the Virginia COVID-19 Equity Leadership Task Force and Health Equity Working Group. The Commonwealth of Virginia integrated principles of equity and inclusion into the infrastructure of state government; an approach that has been instrumental in the state’s response to COVID-19 and beyond.
- The learning network hosted a summit last week on reimagining the collection, reporting, and use of race and ethnicity data across states which will result in a publication later this summer.
- Related: Partnering with Tribal Nations for COVID-19 Vaccinations: A Case Study of Alaska
New Proposed Insurance Rule Opens Enrollment Options; Rescinds Policies of the Trump Administration
In late June, the U.S. Department of Health and Human Services (HHS) issued its first proposed rule governing the health insurance markets and marketplaces. The rule includes some significant changes aimed at achieving priorities outlined in President Biden’s Executive Order to strengthen provisions within Medicaid and the Affordable Care Act (ACA).
Major changes proposed by the rule are summarized below. Comments on the rule may be submitted here by July 28.
Extends open enrollment period for an additional month
The proposed rule would extend the open enrollment period (OEP) deadline from December 15 to January 15. The change would apply to both federal and state-based marketplaces (the FFM and SBMs) and if finalized, would begin with this upcoming enrollment period, which is slated to begin on November 1, 2021.
The December 15 deadline has been in place since the 2018 plan year. States that operate their own marketplaces (SBMs) have flexibility to extend their deadlines beyond this period, and many opt to do so depending on the needs within their markets. Both the FFM and SBMs also have the ability to extend special enrollment periods (SEPs) particularly in the case of exceptional circumstance, as many did to address changing circumstances during the COVID-19 pandemic.
The proposed rule acknowledges that altering the years-long standing deadline may spur consumer confusion and that the current the December 15 deadline ensures that coverage for enrollees will be effective for the full year starting January 1. However, the proposed rule explains that the 45-day enrollment period does not provide sufficient time to assist all applicants and that additional time is needed for these consumers to sufficiently update information and review available plan options. Specifically, the rule cites a pattern of unexpected cost increases experienced by consumers who were automatically reenrolled into a plan without realizing the amount of their federal premium tax credits (PTCs) had decreased due to the existence of lower cost “benchmark plans” (the insurance plan against which PTCs are set). In these cases, the enrollees’ January bill may be the first time they become aware of cost changes and the January 15 deadline gives enrollees some leeway to switch before being locked into a potentially unaffordable option for a year.
Beyond requesting information on potential impacts of the proposed rule on insurance markets and enrollees, HHS is soliciting ideas for proposed alternate strategies, including possible institution of an SEP for enrollees who experience cost increases because of changes to their benchmark plan. In addition, HHS invites comments on flexibilities given to SBMs related to OEPs and SEPs.
Modifications to Section 1332 state innovation waiver program
Section 1332 waivers grant states the option to waive significant portions of the Affordable Care Act (ACA) so long as proposals meet four statutory guardrails:
- Provision of coverage at least as comprehensive as that offered under the ACA
- Provision of coverage as least as affordable as that offered through the ACA
- Assurance that a comparable number of individuals will be insured; and
- Assurance the plan will not increase the federal deficit.
Guidance issued in 2018, and further promulgated in later regulation, set a new interpretation of the guardrail definitions limiting how strictly all of a state’s proposed waiver changes needed to adhere to the guardrails. For instance, the 2018 regulation provided a looser definition of coverage that allows health plans that do not meet the ACA’s standards (ex. short-term plans) meet the criteria of the guardrails. (For more on the 2018 changes see: New Guardrail Definitions Reduce Minimum Requirements for Markets)
Further, HHS proposes to rescind recent rules and guidance, reinstating prior rules requiring that all coverage under a states’ waiver meet the guardrail requirements and clarifying that “coverage” means minimum essential coverage as defined under the ACA. The proposed rule also clarifies some processes related to waiver applications including reinforcing that HHS will not take into consideration waiver proposal elements contingent on the enactment of future state laws or waiver changes (e.g., Medicaid Section 1115 waivers). It also would codify a process by which states may request waiver amendments and clarifies that waiver funding may be adjusted annually based on changes in federal or state laws.
New SEP for low-income households eligible for $0 coverage
The proposed rule would institute a new SEP for individuals and families whose income is up to 150% of the federal poverty level (FPL), allowing them to enroll in marketplace coverage at any point during the year. The change is a direct response to the American Rescue Plan Act’s (ARP) temporary enhancements to the amount of PTCs available to all qualified individuals enabling individuals up to 150% FPL to enroll in a benchmark plan for $0 per month. Prior to the increased subsidy, these individuals would have to pay up to 4.14 percent of their income to purchase a benchmark plan.
The SEP would limit options by allowing eligible individuals to only enroll in a silver-level plan sold through the marketplace. Silver-level plans pose two advantages to enrollees at this income level. First, benchmark plans are set as the second-lowest cost silver plan available to that consumer, so most silver plans could be purchased at $0 to very low cost to the consumer. Second, individuals with income that is less than 250% FPL who enroll in a silver plan also qualify for cost-sharing reductions (CSRs), or subsidies that cover the cost of out-of-pocket expenses such as deductibles and co-pays. Low premium payments and CSRs combine to ensure enrollees high-value health coverage at little to no personal expense.
The SEP would be coupled with dedicated outreach efforts to spread awareness about the opportunity especially to the 20 percent of uninsured individuals estimated to live in households with income below 150% FPL. HHS doesn’t dictate when the SEP would be enacted and proposes to grant discretion to the SBMs about whether to implement the SEP. The proposed rule also doesn’t include requirements for document submission prior to eligibility determinations. HHS requests comments on these issues as well as on anticipated impacts of the policy on insurance markets including adverse selection.
The proposed rule also highlights the potential impact of this SEP given the impending end of the COVID-19 public health emergency (PHE). During the PHE, states are prohibited from disenrolling individuals from their Medicaid programs. Once disenrollments resume, marketplaces are expected to experience an influx of enrollees, particularly of individuals with income below 150% FPL. Currently, these enrollees would qualify for a 60-day SEP triggered by loss of essential coverage, but the proposed SEP would allow these individuals to enroll beyond that 60-day period. (See this blog offer more details about Medicaid and the end of the PHE.)
Reinstates required Navigator program post-enrollment duties
Every marketplace is required to institute a Navigator program—a network of community-based individuals trained to aid consumers with procuring health insurance coverage with a particular focus on serving underserved or vulnerable populations. Recognizing that many enrollees, especially in these targeted communities, need assistance beyond just applying for and enrolling in coverage, the proposal reinstates requirements for post-enrollment assistance
eliminated in the 2020 notice of benefits and payment parameters rule. Specifically, the rule would require Navigators to aid enrollees on topics including eligibility appeals, PTC reconciliation, and basics of using and accessing care. Furthermore, the rule broadens the interpretation of activities to support “use of and access to care” to include help with understanding:
- key health insurance terms,
- cost differences between use of emergency and primary care under selected plans,
- how to identify in-network providers,
- rights to coverage of certain preventive services without cost sharing, and
- common follow-up steps to care such as how to fill prescriptions.
To accomplish these tasks, the rule suggests that Navigators may leverage resources from the Centers for Medicare and Medicaid Services’ Coverage to Care initiative. These reinstated requirements were also reinforced in HHS’ latest funding announcement for Navigator grants.
Repeals Exchange Direct Enrollment option
Rules published in January 2021 established a new option by which states could leverage direct enrollment (DEs) entities in lieu of the FFM or SBM. DEs are private entities (ex., web-brokers, insurers) that are certified to sell marketplace coverage, though they may also sell other products including short-term plans. Individuals may apply for and enroll in coverage through enhanced DEs without ever interacting directly with a marketplace (e.g., healthcare.gov).
Beginning for plan year 2022, the new Exchange Direct Enrollment option would have allowed a state to abolish operation of the FFM or an SBM, and instead rely completely on DEs to enroll eligible individuals in coverage. HHS notes several reasons for proposing to eliminate the option including a need to focus resources on shifted priorities including implementation of the ARP. HHS also noted it had received no interest to date from states wishing to implement the option.
Increases federal marketplace user fee
Operation of the federal marketplace is financed through an assessment on monthly insurance premiums charged to all participating qualified health plan issuers. HHS is proposing a 0.5% increase to the assessment rate to 2.75% in states that use the FFM and 2.25% for states that use they hybrid federal partnership model (SBM-FP). The increases will be used to cover expanded federal services including increased investment in outreach and educational services. HHS anticipates that these investments will lead to improved risk pools, lower monthly premiums, and a reduction in the uninsured and comes on the heels of the federal government’s largest ever investment ($80 million) on Navigators.
Repeals “double-billing” requirement for abortion coverage
The proposed rule would repeal not-yet-implemented requirements on insurers to send separate bills and collect separate payments for premium expenses related to coverage of abortion services. Federal law prohibits use of federal dollars to pay for abortion coverage (except in certain circumstances). To ensure that federal subsidies (PTCs and CSRs) do not pay for such services, insurers are required to separate premium payments used to cover abortion services into a different funding pool and to alert enrollees of the charge by:
- Sending enrollees a notice that their monthly bill included this charge;
- Including the charge as a line item in the enrollees’ monthly bill; and/or
- Sending a separate monthly bill for these services.
Rules finalized in 2019 took these requirements further, mandating that insurers both send a separate bill for the abortion coverage and collect those premiums via payments separate from the enrollees primary premium payment. It was estimated the changes would cost $1 billion from 2020-2023, with $229 million in additional costs each ensuing year to implement.
The proposed rule would repeal 2019 requirements citing excessive administrative and operational burdens caused by the rule as well as ongoing litigation against the rule that had halted its implementation for reasons ranging from its inability to preempt state laws mandating certain billing procedures to incompatibility with federal laws preventing the promulgation of regulations that “create any unreasonable barriers to obtaining appropriate medical care or impede timely access to healthcare services”.
Essential Health Benefit (EHB) compliance with mental health parity
All marketplace plans are required to cover mental health and substance use disorder (SUD) services as part their benefits packages. The proposed rule would enact technical changes to clarify that coverage of mental health and SUD services must comply with all requirements of the Mental Health Parity and Addition Equity Act of 2008 (MHPAEA) including provision of behavioral health treatment services that meet the MHPAEA’s parity standards.
Using Data Strategies to Advance Health and Racial Equity
Data analysis is an essential tool for advancing health and racial equity. Geographic analysis of disease burden has illuminated the impact of racism and identified areas to target interventions. Spurred by the disproportionate impact of COVID-19 on communities of color, states are exploring new strategies to use COVID-19 and other public health data to advance health and racial equity. Convergence analysis, using publicly available data sets, is one such strategy.
During a recent meeting of NASHP’s health equity workgroup, a cross-sector group of state officials exploring and discussing approaches to advance health and racial equity, state officials discussed the need to examine health equity comprehensively as opposed to using a siloed approach that often results from programmatic and grant constraints. A comprehensive focus requires thinking in different dimensions to understand the dynamic interplay of various health conditions and the historical, social and economic context which drive them out of control. Harmonizing publicly available data sets and using GIS mapping tools makes this possible.
Convergence analysis helps to depict the extent that different health conditions coexist at their worst level. Any dataset that is geographically referenced can be used for convergence analysis. State officials, and community groups, can conduct convergence analysis using publicly available datasets including those maintained by the Centers for Disease Control and Prevention (CDC) and the free version of ArcGIS.
In Denver, CO, data from the CDC Behavioral Risk Factor Surveillance System (BRFSS) 500 Cities project was used to determine burdens of the following diseases by census tract: asthma, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, high blood pressure, kidney disease, obesity, and stroke. Convergence analysis revealed that disease burden was greatest in six census tracts that included 32,019 people. African American and Latinx populations were overrepresented in these areas.
Similar convergence analysis was completed for Columbus, OH. Thirty-seven census tracts with a population of 114,835 had at least four of the health conditions at the highest level. In the identified census tracts, 54% of the population is African American, compared to 29% in Columbus overall. These census tracts also face 7.5% unemployment compared to 4.7% citywide.
Inequality and Social Vulnerability
The Mapping Inequality dataset from the University of Richmond can be incorporated into convergence analysis to provide a historical context of the impact of structural racism on health. The Mapping Inequality project digitized the Home Owners’ Loan Corporation (HOLC) maps used between 1935 and 1940. These maps assigned grades to neighborhoods based on their perceived mortgage security to banks and served as a tool for redlining and government-backed residential segregation.
In Denver, CO, areas that had the lowest HOLC grades also had the highest social vulnerability according to the CDC/ATSDR Social Vulnerability Index. The CDC/ATSDR Vulnerability Index identifies communities that may need the most assistance before, during or after a natural or human disaster. This analysis highlights the legacy of structural racism and its impact on health outcomes, especially regarding a community’s ability to respond to an emergency.
The Health Opportunity Index
The Health Opportunity Index is another data strategy for stakeholders invested in health equity. The Index was developed by Rexford Anson-Dwamena, MPH, an epidemiologist at the Virginia Department of Health. The tool can be used to identify which social determinants of health (SDOH) may be driving health disparities in communities at the census tract level.
In an analysis of Ohio’s major cities, the drivers of adverse health outcomes were income inequality, concentrated poverty, food insecurity and segregation. The Health Opportunity Index identifies the challenges and opportunities available to improve health.
State Health Equity Data Tools
The following are some examples of how states are using data to inform their health equity approaches:
- Massachusetts’ Public Health Data Warehouse is a “unique surveillance and research tool that provides access to timely, linked, multi-year data to enable analyses of health priorities and trends, such as the current opioid epidemic and persistent inequities in maternal and child health.” The commonwealth also operates the Population Health Information Tool, a health data portal that includes a health equity dashboard.
- New York maintains a Prevention Agenda Dashboard to track progress on the state’s health improvement plan. Data can be viewed at the sub county level.
- North Carolina created a map of areas with the highest rates of social vulnerability and lowest rates of COVID-19 vaccination. The state encourages vaccine providers to prioritize these areas for outreach and mobile efforts.
- Pennsylvania’s Health Equity Analysis Tool (PA HEAT) includes a dashboard and geographic analysis of health and social determinants of health information at the regional, county, zip code and census tract levels. The purpose of the tool is to “provide a granular geographic perspective of areas that have significant opportunities to improve equity.”
- Rhode Island used geographic analysis of COVID-19 cases during its response to focus on high density areas.
- Virginia’s Health Equity Leadership Taskforce created two dashboards to advance health equity. The Equity in Action dashboard describes how the state is prioritizing equity in COVID-19 response and recovery and the Equity-at-a-Glance dashboard is an assessment of six social determinants of health at the state and local level. The dashboard shows data on income and poverty, educational attainment, food access, unemployment, broadband access, and housing insecurity.
Implications
States looking to engage in data analysis to advance health equity face barriers including missing data, inconsistent standards, and poor tracking of data by race and ethnicity. These issues were illuminated by the COVID-19 pandemic. During the first month of COVID-19 vaccination, data for race and ethnicity was missing for roughly half of people who initiated vaccination against COVID-19. Complete data by race and ethnicity is essential for states to identify gaps in vaccination efforts and better reach historically marginalized populations with COVID-19 vaccines.
Current race and ethnicity categories also limit state officials’ full understanding of disparities among a subpopulation. For example, the category “Asian” covers many subpopulations. A recent Executive Order from the Biden Administration, encourages the Equitable Data Working Group to “expand the collection and use of disaggregated data at the Federal, State, and local level on Asian American, Native Hawaiian, and Pacific Islander communities.”
Further federal guidance could standardize categories and allow for clarity and consistency across federal, state, and local levels. Funding from the American Rescue Plan provides some opportunities for states to invest in their public health data infrastructure. The House Committee on Energy and Commerce is also considering legislation on data, social determinants of health, and health equity.
Access to data and the ability to analyze it geographically is important for helping state officials to equitably distribute resources to address health related social needs. Data analysis is a critical first step for state officials to use their financing, regulatory, and other levers to advance health equity. Creating data maps allows state leaders to visualize areas to prioritize for health equity strategies.
To read more about state initiatives to address health equity, explore NASHP’s toolkit, Resources for States to Address Health Equity and Disparities. If you are a state official interested in joining NASHP’s equity workgroup, please contact Allie Atkeson.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation. NASHP would like to credit Johnnie (Chip) Allen, MPH for sharing the referenced images and data strategies to advance health equity with NASHP’s health equity workgroup.
State Strategies to Mitigate Adverse Childhood Experiences during the COVID-19 Pandemic and Beyond
The COVID-19 pandemic has exacerbated adverse childhood experiences (ACEs), and children could be facing a surge of poor physical and mental health outcomes without adequate investment and focus to reduce the effects of ACEs. This is especially important because Black, Latinx, and Native American children, who already disproportionately experience higher levels of ACEs, have also been impacted by the COVID-19 pandemic, in part due to longstanding inequities. A number of states are taking action. States like California and New Jersey have launched statewide initiatives to mitigate the long-term effect of traumatic events, and several state legislatures have introduced bills to identify and address ACEs in partnership with systems such as Medicaid and education.
State Initiatives to Address ACEs
In California, the ACEs Aware Initiative focuses on screening children for ACEs and working to address the impact of toxic stress, as NASHP has previously highlighted. California set a goal of reducing ACEs by one half in a generation and is working towards this goal in a multi-faceted, community-oriented approach. Through the ACEs Aware Initiative, and in collaboration with the California Department of Health Care Services, the state has distributed nearly $45 million in grants to more than 120 communities. Grantees work to educate providers and community members to recognize exposure to racism as a risk factor for toxic stress and ACEs. Grantees also highlight the importance of prevention, treatment, and healing. For example, several grantee sites assess children for resilience as well as trauma. Individuals who are racially marginalized (Black, Latinx, Native American, or multi-racial) are more likely to experience confounding ACEs and toxic stress in childhood, including lack of access to quality health care or education, or disproportionate involvement in the criminal justice or welfare systems. Because new crises like COVID-19 are more likely to disproportionately affect racially marginalized populations, the ACEs Aware Initiative centers equity as a core component of the program.
In New Jersey, the Department of Children and Families’ (DCF) Office of Resilience released a statewide action plan in 2021 with a goal of helping children and families in New Jersey reach their full potential by focusing on prevention and reduction of childhood trauma and adversity in future generations. The DCF Office of Resilience was created in June 2020 during the pandemic, to host, coordinate, and facilitate statewide initiatives with the purpose of raising awareness of and creating opportunities to eradicate ACEs through grassroots and community-led efforts. Key components to implementing the new action plan include:
- Conducting a statewide literature and programmatic review to assess current efforts to address ACEs in the state,
- Meeting with non-governmental organizations to ensure actions are community-led and centered, and collaboration to highlight and promote an online community, and;
- Making data from the New Jersey Population Health Cohort study publicly available.
Both state strategies center community voices and highlight resilience as a protective factor against trauma, and both plans work in stages by first identifying the breadth and depth of trauma in children through screenings, and then using this information to create appropriate resilience-focused programs. Both California and New Jersey strive to proactively address the impact of ACEs, especially as children are exposed to compounding trauma living through a pandemic and help build a healthier future.
Proposed State Legislative Strategies
COVID-19 has exacerbated existing stressors and the trauma from the pandemic has created new ones, and states have been having active discussions about how best to serve the needs of children during the pandemic. Against this backdrop, legislators across states are considering new strategies to address ACEs. Most states’ legislative cycles are reaching their end and bills are at various point in the legislative cycle, but common themes in proposed legislation include:
- Publicly acknowledging the impact of trauma and importance of trauma-informed care. Illinois SR 212 declared May 25, 2021 “Trauma-Informed Awareness Day,” to, among other things, encourage all employees of the State to become informed regarding the generational impacts of ACEs, toxic stress, and systemic racism.
- Creating entities to identify areas of need and recommendations. A bill in Georgia seeks to create a House Study Committee on ACEs to improve the health of women and children. The bill was introduced after data from the U.S. Health Resources and Services Administration showed that in 2019, 23.6% of Georgia children lived in economic hardship, that economic insecurity is the most common ACE, and non-Hispanic Black children are nearly twice as likely to experience one or more ACEs. Similarly, a Maryland bill proposes establishing a “Workgroup on Screening Related to Adverse Childhood Experiences,” tasked with updating and developing screening tools, submitting the screening tools to the Department of Health, studying best practices, and making recommendations to the Governor and General Assembly.
- Increasing ACE and social determinant of health screening for children by Medicaid and education agency stakeholders. State legislatures are exploring:
- Requiring home health care professionals to use ACE questionnaires to assess patient health risk with reimbursement by Medicaid (NY).
- Requiring school district board of directors to conduct ACEs screenings for any child before taking disciplinary action and including the results in any reports explaining the disciplinary results (AR).
- Screening students for ACEs or traumatic events (CT, MD, PA). Pennsylvania’s bill requests a comprehensive analysis to identify an age-appropriate measuring tool that can be used by school districts to measure childhood trauma. Maryland’s bill requires the Secretary of Health to approve ACE training programs that providers can complete, to be reimbursed by Medicaid.
Next Steps
Unfortunately, nearly 40,000 children lost parents to COVID-19, and sustained investments will be critical to mitigate the effects of the trauma experienced during the pandemic. States are at different stages of promoting ACE awareness and addressing the effects of ACEs–identification and screenings are just the first steps toward improving long term health outcomes. Ongoing efforts to shine a light on this issue are moving ACEs towards mainstream consciousness at a critical juncture. As strategies in California, New Jersey, and other states demonstrate, awareness, community engagement, provider training, and critical partnerships are the first steps toward ensuring that children’s needs are considered and met. NASHP will continue to monitor state action including use of American Rescue Plan Act Funds to address ACEs. See related NASHP resources.
State and National Strategies to Increase COVID-19 Vaccine Confidence
With vaccine supply outpacing demand, boosting public awareness and confidence in COVID-19 vaccines remains critical. Federal, state, and local governments are identifying and employing strategies to improve vaccine confidence across different populations. In NASHP’s recent webinar, “State Strategies to Improve Vaccine Confidence,” speakers from the Centers for Disease Control and Prevention (CDC), the Oregon Health Authority, and AM TRACE discussed strategies and shared tools policymakers can employ to achieve this goal.
As more than half of all American adults are fully vaccinated, and children 12 years and older continue to receive their vaccinations, states are working to further increase access, removing barriers, and providing incentives for those who are yet to be vaccinated. Recent polling shows that up to 40 percent of adults fall into one of several camps: those who will “wait and see”, those who will only get the vaccine if required, and those who will definitely not get the vaccine, and strategies to reach these different groups vary. Vaccination rates also vary by state: 14 jurisdictions have vaccinated 70 percent of all adults with at least one dose of a COVID-19 vaccine, while in other states, less than 40 percent of the adult population has received one dose. Experts believe that many individuals can be persuaded to receive a COVID-19 vaccine if approached with appropriately targeted strategies, and that outreach efforts should be focused on these populations, rather than those who report that they will definitely not get the vaccine.
Building vaccine confidence requires multi-pronged, tailored strategies to engage with and listen to communities to help build trust in the COVID-19 vaccines and the policies and processes that led to their production. State health officials have found that those with concerns about the vaccines are more receptive to messaging from familiar individuals, like their physicians, clergy, and other community leaders. Partnerships with trusted individuals and local institutions, like schools, universities, and employers, are also key to building confidence, especially among those who are more hesitant.
National Approaches to Building Trust
AM TRACE shared research findings during the webinar that mass marketing campaigns have less effect on individuals in the “wait and see” and “probably not” groups – those typically considered to be in the “movable middle”. AM TRACE recommends conducting refined analyses to better understand each target audience’s hesitations and using this information to create localized and personalized messaging campaigns to tailor to these needs.
Federal, state, and local government agencies also underscore the importance of tailoring messages to specific populations and localities to ensure that the vaccine information provided best addresses each community’s needs and concerns. CDC’s Vaccinate with Confidence program gives strategies to help build trust in a variety of key public health and medical tools, including the COVID-19 vaccines, the vaccine-administrating providers, and more generally, the processes and policies that lead to the vaccine development, licensure, authorization, manufacturing, and recommendations for use. For example, CDC developed a rapid community assessment guide to help health departments understand drivers of low vaccine uptake and identify potential interventions. And, CDC’s Confidence Consults1 provide one-on-one support and technical assistance for building COVID-19 vaccine confidence and are available to state, territorial, and tribal immunization programs. The CDC continues to emphasize building trust among individuals and communities and using that trust to promote vaccine confidence among health care providers, who in turn, will recommend the COVID-19 vaccines to their patients.
AM TRACE’s campaign planning tool is another resource that states can consider using to promote vaccine confidence. This tool supports agencies in developing and implementing localized campaigns with personalized messaging, including a micro-targeting, tailored approach, intended to address a variety of factors that influence hesitancy by using a target audience analysis framework. These tools, in collaboration with a strong state and federal emphasis on data collection and analysis to identify vaccination trends and gaps, can help prioritize priority populations and tailor strategies to improve vaccination rates.
State Strategies: Featuring Oregon
The Oregon Health Authority (OHA) and Oregon Department of Human Services presented a variety of tailored approaches to identify populations and reach out to encourage vaccination in effective ways. For instance, OHA identified challenges in reaching Oregon’s Latinx populations, and subsequently developed a coordinated state response that included: a statewide communication strategy, close partnership with community-based organizations and local health departments, connections with trusted Migrant and Community Health Centers, and a radio talk show where Latinx community members can connect and share their experiences.
Other efforts to provide tailored communication approaches in Oregon include:
- The Oregon Youth Authority (OYA) created resources and vaccine messages in multiple languages for various populations, including youth in OYA custody, and Latinx, Black, and Native American youth and families. OYA’s flyers include messaging around the importance of vaccination from high-profile and trusted messengers, including Vice President Kamala Harris, United States Representative Alexandria Ocasio-Cortez, and physicians of color.
- OHA developed a weekly series, Vaccine Voices, to help address vaccine hesitancy, during which people from a variety of communities who have gotten their vaccine can share their stories and experiences with the process to help alleviate concerns.
Other states officials have shared with NASHP various new strategies to reach specific populations in culturally appropriate ways. For example, some states are organizing community vaccination clinics in popular venues. Kentucky organized a “Derby Day” campaign, which included vaccinating individuals at Churchill Downs, the site of the Kentucky Derby, Alabama set up a vaccine site at the Talladega Superspeedway, and Wyoming has set up sites to vaccinate young people and families at drive-in movie theaters.
Additionally, to promote vaccine confidence among parents and adolescents, many states are partnering with school districts, including working with superintendents and teachers. In some instances, states are locating vaccine clinics on school grounds, which allow people to get vaccinated in a familiar and easily accessible setting. Some health departments are also working with schools to send out targeted educational materials. For example, the Louisiana Department of Health teamed up with the Louisiana Department of Education to distribute flyers to students with FAQs about vaccines for adolescents. New York City is launching a pilot program with four schools in the Bronx as a site for children 12 years and older to get vaccinated, and will be hosting community conversations with parents, educators, and youth. Many states are using these school-based sites as an opportunity to encourage entire families to get vaccinated together.
Experts during the NASHP webinar noted that building trust and vaccine confidence requires patience, time, and trusted messengers. It requires identifying the differences between the need to build vaccine confidence, provide education, and reduce barriers to access. It also requires identifying that these needs differ based on the state and community, and that data is a critical component for states to accurately identify pockets of need and target successful strategies. As states roll out new vaccination strategies and build on existing best practices, NASHP will continue to analyze distribution efforts and support states in identifying effective and successful approaches.
This blog is sponsored by AM TRACE with content development at the sole discretion of NASHP.
Endnotes
- For a CDC Confidence Consult, state and/or jurisdictional health departments can email requests to confidenceconsults@cdc.gov
State Opportunities to Strengthen Home and Community-Based Services through the American Rescue Plan
The American Rescue Plan of 2021 (ARP) – signed into law on March 11, 2021 – provides states with a one-year, 10 percentage-point increase to the federal medical assistance percentage (FMAP) for Medicaid expenditures on home and community-based services (HCBS) for children and adults. This increase provides states with a critical opportunity to address both emerging and long-standing challenges in state long term care systems – systems that have been heavily impacted by the COVID-19 pandemic in the last 14 months. The Center for Medicare & Medicaid Services (CMS) issued a letter to State Medicaid Directors on May 13, providing additional guidance to states on how they can use this new funding.
Highlights from CMS guidance:
- The increased FMAP must be used to supplement, not replace, existing state funds spent on Medicaid HCBS in effect as of April 1, 2021.
- State funds equivalent to the amount of the increased FMAP can be used to facilitate activities that enhance, expand, or strengthen Medicaid HCBS.
- States are prohibited from imposing stricter eligibility requirements for HCBS programs and services than were in place on April 1, 2021, and may not eliminate covered services or reduce the amount, duration, or scope of those services during this period.
- CMS will not apply penalties or non-compliance restrictions to states once the authority for temporary changes to HCBS eligibility, coverage and/or payment rates (e.g., Appendix K waivers and disaster relief state plan amendments) has expired or if the state needs to implement changes to comply with federal requirements
- CMS will work with states making programmatic changes to revise cost effectiveness projections appropriately and determine the feasibility of their budget neutrality models.
While the enhanced FMAP increases federal funding for specific services, the impact of the 10% bump could have broader implications for state HCBS systems. States may use state dollars freed up by the enhanced match to “enhance, expand, or strengthen” Medicaid HCBS in myriad ways. State context and specific priorities will drive these investments, which could include:
- Bolstering workforce: COVID-19 has highlighted the need to better support the long-term care workforce. States can target resources to increase wages and benefits, facilitate vaccinations and other COVID protections, and invest in training and career pathway strategies to grow and sustain a diverse LTC workforce, including peers and community health workers.
- Addressing equity: Expanding access to HCBS services in underserved communities and communities of color is a critical priority across states: policy makers may choose to enhance cultural and linguistic capacity, assess and address equity through existing No Wrong Door Systems, and invest in community-based organizations that are located in and serve communities especially hard hit by the COVID pandemic.
- Supporting family caregivers: Families can be critical to keeping adults and children and youth with special health care needs (CYSHCN) at home or in community settings. States may want to increase services and supports for families, including respite; establish or strengthen family caregiver assessment and outreach; build greater cultural and linguistic capacity; enhance Medicaid self-direction programs that pay families and others to provide Medicaid services, and facilitate wider use of innovative technology.
- Investing in behavioral health recovery: The higher match rate is also available for services to support people in recovery from mental illness and substance use disorders. Enhancements could include strengthening community-based interventions that help people remain in housing or stay employed; building cross-system reentry capacity with state prisons or local jails; developing diverse peer support capacity for people with behavioral health disorders; improving transitions for youth with behavioral health needs, and promoting access to recovery options for children, youth, and adults in underserved areas.
Additional considerations for states
States will have to quickly identify priorities and focus areas, identify services available for the enhanced FMAP, and submit plans and budgets within a very narrow timetable. Other issues to consider:
Sustainability: The enhanced FMAP is only available for one year; additional state funds that result from the enhanced match are available to support HCBS activities through March 31, 2024. States that opt to expand access to HCBS will want to plan for sustainability of services, both after the initial one-year FMAP bump, and through 2024 when all additional resources need to be spent.
Waiver/SPA rules still apply: States may add new services to maximize impact of the FMAP bump, but may need to submit a waiver or state plan amendment to do so. CMS will work with states to ensure state compliance with cost neutrality and budgeting rules.
State planning and initiatives: States may already have legislative and other state policy initiatives in the works that impact their HCBS systems. These ongoing or upcoming initiatives may benefit from ARP funding and can be incorporated into state submissions.
The American Rescue Plan funding represents an important opportunity for state policy makers to address long-standing challenges in HCBS systems related to access, rebalancing, health equity, workforce, and other issues. Initial state plans are due to CMS within 30 days of May 13th. CMS indicates it will publicly post state plans; NASHP will track these plans as they are posted and share information on emerging themes.
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. 
