State Strategies to Increase COVID-19 Vaccination Rates in Children
COVID-19 vaccines have been available for children ages 5-11 since October 29, 2021. As of March 16, 2022, the Centers for Disease Control and Prevention (CDC) reports that just one-third (33%) of children in this age group have received their first vaccine dose, with vaccination rates varying widely by state. Just twenty-six percent of 5–11-year-olds have been fully vaccinated.
The ten states with the highest fully vaccinated rates among children ages 5-11 years (Vermont, Massachusetts, Rhode Island, Hawaii, Maine, Maryland, Connecticut, Virginia, Minnesota, and Illinois) have adopted creative approaches to promoting COVID-19 vaccination.
This blog highlights several of these approaches, which states may consider adopting when encouraging parents to get their children vaccinated against COVID-19 and other vaccine-preventable diseases. These strategies may be extended to vaccination activities for 6-month to 4-year-olds once COVID-19 vaccines receive emergency use authorization for this age group from the U.S. Food and Drug Administration.
Incentives
Many states have offered incentives to encourage COVID-19 vaccination. These incentives range from college scholarships to free food, with mixed results when evaluated for impact on vaccination uptake. A randomized clinical trial in Sweden in 2021 demonstrated that monetary incentives increased vaccination rates by approximately 4 percent. Other research has suggested incentives are most effective when three criteria are met: receipt of the incentive is certain, incentives are delivered immediately, and the recipients value the incentives. Several states in the top 10 for vaccine coverage offered incentives for vaccinating children ages 5-11, including:
- Vermont created the School Vaccine Incentive Program in December 2021, which provides monetary awards to schools achieving an 85 percent student vaccination rate. Schools are awarded $15 per vaccinated student with a minimum award of $2000 and a maximum award of $10,000. Schools achieving at least 90 percent student vaccination rate can apply for an additional 50 percent of the initial award, up to a maximum award of $15,000. The state is using federal emergency funds to support the program, which runs through April 1, 2022.
- Minnesota launched its “Kids Deserve a Shot!” campaign, providing families with a $200 Visa gift card if their 5-11-year-old child received both doses of a COVID-19 vaccine between January 1 and February 28, 2022. More than 22,000 children registered to receive a gift card as a result of this program. On March 1st, the Governor announced that any Minnesota parent or guardian whose 5 to 11-year-old had ever received both doses of COVID-19 vaccine by April 11, 2022, can enter to win one of five $100,000 Minnesota College Scholarships. This strategy was modeled after the state’s successful program to vaccinate children ages 12-17.
- Six months after 12-17-year-olds became eligible, the state launched the program to help drive up vaccination in the youth population, which had the lowest vaccination rate at the time. Within one week of the start of the campaign, first dose vaccinations increased nearly 40%. The state offered a $200 Visa gift card for 12-17-year-olds who started and completed their vaccine series within a six-week window, and five drawings of $100,000 Minnesota college scholarships for any Minnesotan 12-17 years old with a complete vaccine series.
School-located Vaccination Clinics
States play an important role in the success of school-based COVID-19 vaccination clinics. States can support schools with coordination of efforts, financial support, and media outreach in addition to providing vaccination supplies, personal protective equipment, and personnel to support these activities.
- Virginia recently published a playbook to support school-based vaccination events. “Vaccination of the School-Age Population in a School Setting and in the Community: Playbook to Support Vaccination Events” was created in partnership with the state’s immunization coalition, Vaccinate VA, and provides information for planning and conducting school-located COVID-19 vaccination clinics for the 5- to 11-year-old population.
- Connecticut published its “#Vax2SchoolCT” toolkit, which outlined step-by-step logistical considerations and recommendations for promotion and outreach. The toolkit provides a letter template for communications to students and families as well as information on the state’s “Vaccine+ Program,” which connects families to resources such as water and heating assistance.
- In Hawaii, schools were the main staging ground for administering COVID-19 vaccinations to children ages 5-11, with over 100 public, private, and charter schools holding vaccination clinics.
- Illinois organized 756 elementary school districts to offer vaccination clinics for students ages 5-11 on school grounds. Their mobile vaccination teams conducted more than 870 school and youth events when vaccines became available for 12-17-year-old students.
Parent-friendly Websites
States can provide public-facing information that is easy to access and navigate and that makes choosing to get vaccinated the easy choice. Several states have webpages dedicated to COVID-19 vaccinations for children.
- Vermont’s dedicated website for pediatric COVID-19 vaccines, “Just for Them!”, provides an online consent form and pre-vaccination checklist translated in many languages. Twenty-five percent of Vermont’s 5–11-year-old population registered to receive a vaccine within eight hours of opening registration to the public.
- Minnesota posted their “COVID-19 Vaccines and Kids: What Pediatricians Are Saying,” video to the state’s website, providing information to parents who may be hesitant about getting their children vaccinated.
- Massachusetts has a dedicated website for COVID-19 vaccines for 5-11-year-old children that includes a downloadable consent form, answers to frequently asked questions, and includes a chatbot that can answer COVID-19 vaccine-related questions in real time.
Partnerships
States can partner with organizations such as their state chapter of the American Academy of Pediatrics, state and local immunization coalitions, and hospitals to help build confidence in COVID-19 vaccines and improve access to vaccination for children. For example:
- Vermont and the Vermont Chapter of the American Academy of Pediatrics partnered to provide Facebook live “Chapter Family Forum” events featuring Vermont pediatricians who discussed the importance of vaccinating children against COVID-19.
- Rhode Island and Lifespan’s Hasbro’s Children’s Hospital partnered to provide hospital-based COVID-19 vaccination clinics for children ages 5 to 11.
- Minnesota partnered with the Mall of America to vaccinate children. The Mall of America clinic had the capacity to vaccinate 1,500 children per day.
- Massachusetts partnered with museums such as the Discovery Museum in Action, Boston’s Museum of Science, and the EcoTarium Museum to offer age-specific vaccination clinics for younger children.
- Illinois announced that the Illinois Department of Public Health had “reached out to every pediatrician in the state to enroll them in the vaccine distribution program” and then called on parents to call their pediatricians and make sure they had enrolled and ordered doses. The state enrolled more than 2,200 locations to provide vaccinations to 5-11-year-olds, including more than 700 medical practices, more than 700 pharmacies, 100 urgent care centers, 112 local health departments and public health clinics, 270 federally qualified health centers, more than 200 hospitals, and dozens of rural health clinics.
Media
Federal funding has provided states with unprecedented opportunities to create media messages promoting COVID-19 vaccinations for children. States can play a vital role in building vaccine confidence and promoting vaccination for children through media. Examples of such messages include:
- Vermont partnered with Vermont Public Radio’s “But Why: Podcast for Curious Kids” to explain the importance of kids getting COVID-19 vaccines and hear from kids who took part in COVID-19 vaccine trials.
- Maine announced a contest for children ages 5 to 17 to create a short video that explains the benefits of getting the COVID-19 vaccine or the risk of not getting vaccinated. The first place winner was awarded $50,000 for their school, with $25,000 going to second place and $10,000 to third place. Schools can use the prize money to supplement school meals with healthy treats; purchase playground, classroom, gym, sports, or music equipment; enhance a special school activity; or support a school field trip for all students.
- Maryland partnered with the Maryland Chapter of the American Academy of Pediatrics to create a public service announcement featuring pediatric health care providers from around the state who encourage parents to get their children vaccinated against COVID-19.
- Illinois, in partnership with the Illinois Chapter of the American Academy of Pediatrics, created a COVID-19 Pediatric Vaccine Social Media Toolkit to provide credible, informative, and diverse social media messaging to promote COVID-19 vaccination for children ages 5 years and older. The toolkit included pediatric vaccination flyers, social media digital resources, and videos, including a video from the director of the Illinois Department of Public Health, Dr. Ngozi Ezike, who is a board-certified internist and pediatrician and the first Black woman appointed to lead the agency.
With FDA emergency use authorization of COVID-19 vaccines on the horizon for children ages 6 months to 4 years-old, states will need to continue to find new and innovative approaches to encourage parents to vaccinate their children and to ensure vaccinations are readily accessible.
Moving Toward Prevention: Oregon Launches Kindergarten Readiness Metric
Oregon has launched a new kindergarten readiness metric in its Medicaid program. Early childhood is a critical time for growth and development, and the services and supports children and their families receive early on can have a large impact on health outcomes later in life. Because COVID-19 has exacerbated existing health disparities, including for young children, state officials are looking for new ways to support healthy child development and advance health equity. Oregon has promoted healthy child development for decades, with a particular focus on the social-emotional health of young children. The state’s new kindergarten readiness incentive metric focused on social-emotional health renews that commitment and helps solidify the connection between a child’s health and their success in school and beyond.
In the 2000s, Oregon worked with the National Academy for State Health Policy (NASHP) in the Assuring Better Child Health and Development (ABCD) Program. One of the state’s major goals at the time was to increase developmental screening for young children. One of the levers Oregon used to achieve this goal was to include developmental screening as an incentive measure for coordinated care organizations (CCOs)—a successful approach that led to one of the best developmental screening rates in the country. At that time, there was also interest in outcome-based kindergarten readiness metrics and a sense that CCOs could help ensure that children have their health-related needs met before entering the school system. NASHP staff recently interviewed state officials in Oregon about how the state has progressed from incentivizing developmental screening to creating a kindergarten readiness incentive measure that prioritizes children’s social-emotional health.
Kindergarten Readiness and Social-Emotional Health
For many children, kindergarten is their first contact with the education system. Those who arrive in the classroom with the skills and supports they need are more likely to have a positive experience, to succeed in school, and to have a healthy life. With the leadership of the Children’s Institute in collaboration with the Oregon Health Authority and Oregon Pediatric Improvement Partnership, Oregon formed the Health Aspects of Kindergarten Readiness Technical Workgroup in 2018 to identify the health aspects of kindergarten readiness and to offer recommendations about how to measure them. The workgroup, which was made up of pediatricians, early learning partners, families, and others, identified physical, oral, developmental, and social-emotional health as key aspects of kindergarten readiness in a 2019 report. The workgroup identified a need for systems-level change with social-emotional health as a priority focus area.
In conversations with NASHP, stakeholders in Oregon described unidentified or untreated social-emotional health delays as a factor that contributes to long-term educational inequities by increasing both the likelihood of classroom behaviors that are viewed as difficult and the likelihood of disciplinary action. Additionally, national data shows that children of color, particularly those who are Black or Indigenous, are more likely to have one or more adverse childhood experiences (ACEs) than white children—which can negatively impact social-emotional development. An Oregon health official shared that when children have ACEs and also experience racism, the supports available are often not matched to cultural needs and the response to social-emotional delays can further perpetuate health inequities.
In Oregon, children with social-emotional delays are not as likely to receive follow-up care as children who screen positive for other health needs. The Oregon Pediatric Improvement Partnership (OPIP) has led improvement work in 13 counties to focus on follow-up to developmental screening and consistently found that children with social-emotional delays rarely received follow-up services and a contributing factor is the lack of services available for children birth to age five.
Development of a CCO Incentive Measure for Kindergarten Readiness
In Oregon, the Medicaid CCOs, the state’s version of an “accountable care organization,” share financial and medical responsibility for physical, behavioral, and oral care with the state for providing coordinated care in order to limit unnecessary spending. The Oregon Health Authority (OHA) provides CCOs with a fixed global budget that allows them the flexibility to implement new ways of paying for and delivering care, using strategies that are best suited for their members. In addition to standard performance measures, a set of incentive measures is linked to a CCO quality pool fund. CCOs must meet benchmarks for performance on these measures to be eligible for incentive payments from the quality pool.
The Health Aspects of Kindergarten Readiness Technical Workgroup was tasked with identifying and assessing existing kindergarten readiness metrics to identify gaps and ultimately recommending metrics that could address health and be part of the CCO incentive measure set. After the 2019 measure recommendations were unanimously endorsed by state measurement committees, in 2020, Oregon began implementing readily available incentive metrics for children’s preventive dental and well-child visits. Then, informed in part by the OPIP pilot programs and the lack of services to address children’s social-emotional needs, the group recommended that CCOs work to incorporate a child-focused social-emotional kindergarten readiness incentive metric. The group recommended a strategy for building capacity to provide follow-up services and care: the suggested incentive measure would first require CCOs to do the community outreach and planning to develop needed resources and strengthen connections to services.
A team made up of individuals from the Children’s Institute and OPIP developed the novel metric, which was supported by the Oregon Health Authority. The team presented a proposal to Oregon’s Metrics and Scoring Committee in November 2020 and then carried out pilot activities with the CCOs in early 2021. The resulting Health Aspects of Kindergarten Readiness Measure: System-Level Social-Emotional Health Metric was endorsed a metric and is included in the 2022 incentive measure set. As the CCO Metrics 2020 Final Report shows, distribution of quality pool funds is based on the number of total incentive measures a CCO meets and the CCO’s size.
Implementation and Next Steps
The kindergarten readiness metric is transformative and anchored to community engagement, stakeholder input, and hearing from marginalized communities in order for the CCO to attest to completing specific activities. Over the four years that the system-level incentive metric is in place, the CCOs will be asked to complete activities that fall into four specific components that require:
- Social-Emotional Health Reach Metric Data Review and Assessment
- Development of an Asset Map of Existing Social-Emotional Health Services and Resources
- CCO-Led Cross-Sector Community Engagement
- Development of an Action Plan to Improve Social-Emotional Health Service Capacity and Access
The CCOs will engage communities, create asset maps to identify what services are available, and review data for populations with historical inequities—breaking out the data by ACEs, medical complexities, race and ethnicity, zip codes, and more. At the end of the first year, the CCOs will design an action plan with community input about where to focus improvements. Over the remaining years the CCOs will continue to track and analyze the data to identify barriers and facilitators and to inform the transition to a child-focused social-emotional kindergarten readiness incentive metric at the end of the fourth year.
A key focus is assessing how the data, asset map, community engagement, and action plans can be informed by and address the specific needs of historically marginalized populations. Oregon has adopted the strategic goal to end health inequities in the state of Oregon by 2030. Implementing strategies among young children that promote health equity and equitable educational achievement is one way that Oregon is working toward a more equitable future for all inhabitants. As children’s health, mental health, and development opportunities continue to be a primary focus of COVID-19 recovery efforts, incentive-based approaches hold great promise to eliminate disparities experienced by children from historically marginalized communities.
States Plan for the End of the Medicaid Continuous Coverage Requirement
State officials are actively planning for the eventual end of the Medicaid continuous coverage requirement that is currently associated with the federal COVID-19 public health emergency (PHE) and enhanced federal Medicaid matching funds. The continuous coverage requirement has ensured that individuals enrolled in Medicaid throughout the pandemic are not at risk of losing coverage. However, unwinding this provision will require individuals to complete renewals necessary to redetermine their eligibility to remain in the program. Medicaid officials are focused on ensuring that eligible individuals do not lose coverage when it is time for their renewal.
The timing and federal requirements of unwinding the Medicaid continuous coverage requirement is currently unknown. Federal guidance has been evolving with more, significant, changes expected soon, including reduced federal funding to states. Read more about the proposed changes in this NASHP blog.
The unwinding of Medicaid’s continuous coverage will require significant policy and operational shifts that involve eligibility system and other technological changes. While states will need time to effectuate some of these changes, some are waiting until federal requirements are finalized to operationalize changes to avoid incurring excess costs associated with unnecessary large-scale system changes. In the meantime, state Medicaid officials are seizing opportunities to lay important groundwork including improving communications with members and strengthening partnerships.
Improving address and contact information
Throughout the pandemic, Medicaid enrollees have not needed to complete renewal process to maintain coverage. Given that the Medicaid continuous coverage provision has resulted in less frequent communication with enrollees, there is widespread concern that states may not have up to date contact information, including addresses for all enrollees. Economic instability due to the pandemic resulted in more people being transient in the last year, exacerbating the likelihood of outdated address information. This could result in eligible individuals losing coverage because they did not receive renewal notices, and therefore they may not take action to return necessary paperwork to the state. In preparation, states are exploring multiple avenues to gather accurate address and contact information for their enrollees, including data sharing agreements with the US Postal Service, as well as other state agencies and public benefit programs.
State agencies are also seeking to enlist assistance from their Medicaid managed care organizations (MCOs) that may have more recent contact information on their enrollees as enrollees may be more actively interacting with their insurance carrier. In recent discussions with state officials about returned, undeliverable mail, several states also indicated that they are exploring contracting with vendors to research more accurate address sources and provide the agency with up-to-date contact information for individuals not receiving state correspondence. In addition, states are working proactively to gather new information at any point of contact with members, including granting new permissions to call center staff who were previously unable to update contact information.
Identifying best practices for outreach and communications
Consumer education is critical to ensuring that individuals are not inappropriately disenrolled from coverage when normal eligibility determination operations resume. Members who newly enrolled in Medicaid coverage during the PHE may be unfamiliar with the Medicaid renewal process and actions typically required to maintain enrollment. Some states are taking added steps to ensure that notices are distinct from communications sent throughout the pandemic and convey the appropriate level of urgency, while also meeting readability standards for their consumers. Some states have engaged community perspectives in drafting communications such as member advisory groups to ensure that messages are effective to help with disseminating communications.
In addition, states will need to communicate with individuals and families who benefited from coverage premium holidays or other payment flexibilities under a COVID-19 disaster state plan amendment (SPA). As protections adopted under disaster SPAs are tied to the expiration of the PHE, states are beginning to communicate with members to prepare them for upcoming changes.
Developing strategies for processing and staggering renewals and redeterminations
States are developing plans to approach the large volume of eligibility redeterminations and verifications they will need to process following the termination of the Medicaid continuous coverage requirement. Most states have continued to process coverage renewals throughout the PHE and many report that there are a significant number of individuals that have not provided necessary information to verify their eligibility. These individuals have not been disenrolled but will need attention as Medicaid unwinds the continuous coverage requirement. States are utilizing different strategies to ensure they will have the capacity and information needed to effectively process renewals. Such strategies include:
- Timing: Several states have expressed the need to stagger these individuals’ renewals over a 12-month period to ensure there isn’t a disproportionate volume of renewals like this every year into the future. Medicaid staff will also need ample time to complete eligibility verifications for individuals that return their renewals, as well as time to act on any reports of changes in circumstance from enrollees that may affect their Medicaid eligibility.
- Staggering renewals: Consistent with federal guidance, some state officials will opt to conduct renewals by prioritizing groups. For instance, some states intend to first identify and process those enrollees who are most likely to be ineligible for Medicaid, and one state indicated that they will prioritize eligibility redeterminations for the optional COVID-19 testing group.
- Alignment with other eligibility determinations: States adopting the 12-month postpartum coverage option under the American Rescue Plan Act may consider aligning redeterminations for individuals covered under the pregnant persons group until after the coverage expansion has taken effect in April 2022.
Partnering with state health marketplaces
Some Medicaid agencies in states with state-based marketplaces are partnering to identify strategies to ease the transition to commercial coverage for individuals deemed ineligible for Medicaid. Through consistent communication and collaboration, state Medicaid agencies and health insurance marketplaces are working to mitigate barriers and facilitate shifts into marketplace coverage, including collaborating on shared language used in notices and outreach materials, clear communication on timing of changes, and efforts to share, where possible, appropriate data about enrollees. States are also exploring opportunities and potential benefits of easing transitions between programs, especially where the same carriers participate in both Medicaid and the Marketplace.
As federal direction is finalized on how to unwind the continuous coverage requirement, states will have more information that will allow them to take further action and assist in their planning. In the meantime, they are thoughtfully approaching this huge task and leveraging the resources they have. NASHP will continue to engage states and track their efforts moving ahead.
State Actions to Prevent and Mitigate Adverse Childhood Experiences (ACEs)
This brief highlights the recent work of nine states (Alaska, California, Delaware, Maryland, New Jersey, Pennsylvania, Tennessee, Virginia, Wyoming) to prevent and mitigate adverse childhood experiences (ACEs) and to implement trauma-informed practices at the state level. Experiencing adversity in early life can affect a person’s health, well-being, and success into adulthood. COVID-19 has brought additional attention to the impact of ACEs and trauma across the lifespan, which may be exacerbated by disruption in the lives of families; increased family stressors; income, food, and housing insecurity; social isolation; and school closures. ACEs are common across sociodemographic groups; however, they do not impact all sociodemographic subgroups equally – elevating ACEs as an important locus for states to address health equity. To mount an effective response to ACEs, states are implementing holistic approaches to promoting resilience for children and their families and adopting approaches that combine universal training, access to screening and treatment, improved data collection and reporting, and a commitment to transformative, cross-agency cultural change.
Previous case studies:
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. 
