Hemi Tewarson Shares Her Vision for NASHP’s Future
I am excited to take the reins of NASHP at a critical time for states. Trish Riley – a fantastic leader – has built a thriving and talented organization with staff who are all passionate about working with state leaders. I am honored to continue and build upon NASHP’s excellence and support all of you at the state level. Working in many different venues – private sector, federal government, and non-profit organizations – I have engaged states from all of these perspectives. States are truly the laboratories of democracy – where ideas meet implementation – with the goal of improving the health and well-being of state residents. The opportunities that await are why I am here at NASHP.
States have been at the forefront of the COVID-19 pandemic – having to make decisions quickly with limited time, information and resources. With vaccines and other measures, we are hopefully turning the corner to recovery. I wanted to take a moment to thank state leaders for their tireless work throughout the past year. With your efforts, we have come so far – making incredible progress in a short time. We are now all ready to get back to how we all lived before COVID-19 – it is a time for hope – as well as continued work to ensure we keep everyone healthy.
In the recovery phase of COVID-19, states will need to think through how to invest federal funds to improve the health and well-being of state residents. This will be a complicated process with many options for investment – not only for our long under resourced public health system- but also for those many different areas that impact health such as housing, food security, education, criminal justice, behavioral health, transportation and others. I also remain acutely aware of the disparities that have been aggravated by the COVID-19 pandemic – with Black, Latinx and Native American populations experiencing much higher COVID-19 cases and mortality rates. Though such disparities were present long before this pandemic, we have an opportunity with new federal resources and awareness to take meaningful action to address equity – for communities of color as well as rural and other populations who are experiencing disparities.
As the optimist that I am – I see the next two years as a time of opportunity – to expand and deepen NASHP’s work with states. We stand ready to support states in their efforts to increase vaccination rates as they reopen as well as modernizing the public health system to maintain the health of the population and prepare for future pandemics. In addition, states are getting back to the work they had started before the pandemic – which is now even more critical. These areas include addressing health care coverage and access, curbing costs of the health system, identifying strategies to address equity and social determinants of health, expanding programs for chronic and complex populations, targeting and improving programs for maternal, child and adolescent health, and developing new models for health care payment and delivery reform.
But an ambitious agenda requires partnerships as states cannot do this alone. I anticipate expanding NASHP’s partnerships with state leaders as well as the many entities and organizations that are critical for this work – federal officials, other state organizations, funders, consumers, health systems, health plans, academics, national experts, and others. Your expertise and perspectives will be so important as we look collectively to identify and implement strategies for these longstanding and complex challenges. I look forward to working with many of you in the weeks and months to come.
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
Massachusetts Uses Opioid Legal Settlement to Advance Equity in Access to Medications for Opioid Use Disorder
Nationwide, overdose fatalities continue to climb, and racial disparities in overdose rates persist. Black Americans have experienced the steepest increase in opioid-related overdoses among all groups in recent years, despite the rate of opioid use remaining higher among Whites. While the past few years have seen a significant uptick in the use of buprenorphine to treat opioid use disorder (OUD), research indicates that unequal access to the full range of evidence-based medications for opioid use disorder (MOUD) treatment persists: buprenorphine is more readily available for Whites and those with private insurance or the ability to self-pay; White communities have more access to buprenorphine, while access in predominantly black communities may be limited to methadone.
These trends have played out in Massachusetts, and alarming disparities in data – including a 40 percent increase in overdose deaths among Black individuals despite a decrease of 3.8 percent among Whites – led the state Attorney General’s Office (AGO) to conduct outreach to local stakeholders in the BIPOC community. These leaders noted that one major barrier to treatment was an existing lack of cultural humility in OUD treatment.
This came at a time when the Massachusetts AGO had settled with an Andover-based mail-order pharmacy, Injured Worker Pharmacy (IWP), for unlawful opioid prescribing and dispensing practices targeted at workers’ compensation patients in 2020. The suit followed in the wake of major multistate settlements with pharmaceutical manufacturers and is one among several in which states are pursuing lawsuits against other parties they believe culpable in advancing the opioid epidemic.
$1.5 million of Massachusetts’ $11 million settlement with IWP was dedicated to the AGO to be spent at their discretion under broad guidelines to improve care and treatment for OUD, including through grant programs. Drawing on the issues raised by stakeholders, the AGO directed $1.5 million in grant funding to community organizations to address inequities in access to OUD treatment. The state targeted resources to organizations committed to advancing public health equity, located in the communities they serve, and already using a cultural humility framework and/or the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards).
The Massachusetts grant opportunity, “Promoting Cultural Humility in Opioid Use Disorder Treatment,” was announced in October 2020. Massachusetts considered proposals from non-profits, municipalities, and quasi-public entities that demonstrated a commitment to providing culturally responsive OUD treatment for communities of color and socioeconomically diverse communities across the Commonwealth. The sixteen grantees, which were announced in February 2021, range from statewide to local and tribal initiatives, and plan to address inequities in treatment access through several distinct approaches:
- Multi-Lingual Services: Grantees plan to recruit/retain bilingual staff in clinical settings and develop their bilingual peer support/navigator workforce.
- Workforce development: All grantees plan to develop their workforces, either through training, recruitment, or retention, with a strong emphasis on peer recovery services.
- Other underserved populations: The AGO funded several grantees to address OUD in specific populations. Grantees include the programs which will use funding to target services for individuals experiencing homelessness, veterans, pregnant and parenting people, sex-workers, and individuals re-entering from incarceration settings.
The AGO notes that capacity building is a key component of Massachusetts’ long-term strategy to fight the opioid epidemic, and addressing the unmet needs of the BIPOC community must be central to this strategy. The office further emphasizes that continued conversations with the BIPOC community will inform ongoing work.
The National Academy for State Health Policy is providing this blog with the ongoing support of the Foundation for Opioid Response Efforts (FORE). The authors would also like to thank the Massachusetts Attorney General’s Office for contributing their state experiences for this blog.
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.
Biden Administration Defends Rule, States Move Forward with Importation
On May 28, 2021, the U.S. Department of Health and Human Services (HHS) filed a motion urging a District Court to dismiss the Pharmaceutical Research & Manufacturers of America’s (PhRMA) challenge to a federal rule enabling state importation from Canada. The filing signaled the Biden administration’s commitment to defend the rule, which was published in October 2020 under the previous administration. HHS argued that PhRMA lacked standing to pursue the suit because manufacturers have not been harmed by the rule, and that PhRMA acted prematurely because no state importation program has been federally authorized yet.
The rule establishes the rigorous regulatory requirements that states must fulfill in order to create safe, cost-savings programs – the two core requirements for the federal authorization states must receive before implementing an importation program. During the rulemaking process, the National Academy for State Health Policy submitted comments that are drawn from our work with states to explain the changes needed to help enable successful implementation by states. Though some of the issues raised were not addressed in the final rule, states have proceeded to design programs within the confines of those rules. The action by the Biden administration to defend the rule, if successful, opens the door to negotiations with states about how best to proceed.
Six states have enacted laws enabling them to design Canadian importation program and to pursue federal authorization:
- Two states – Florida and New Mexico – have submitted formal importation program applications following publication of the final rule.
- Three states – Vermont, Colorado, and Maine – filed initial concept applications prior to the publication of the rule, in order to meet deadlines in their state statutes.
- New Hampshire passed enabling legislation, but has not yet submitted an application to HHS.
Florida, whose program design is unique in being limited to public payers, has already contracted with a vendor to run its program, and on Friday Governor DeSantis also announced a new agreement with a Canadian drug supplier. Colorado has also invested resources in advancing its program. In January Colorado issued an invitation to negotiate for a vendor (or vendors) to implement its program. Bidding closed in late April and the state is currently reviewing bids. Colorado’s program, similar to the other states with the exception of Florida, is focused on the commercial market as a strategy to ensure savings to consumers.
In addition to the six states implementing programs, 16 states also considered 23 drug importation bills this session. Some states are also exploring a new, related strategy to establish international reference rates based on Canadian pricing which would essentially allow a state to import Canadian prices in lieu of importing the drugs themselves. Seven states (PA, OK, ND, ME, HI, RI, NC) have introduced international reference rate bills to date based on the NASHP’s model legislation.
Six States Selected for NASHP’s Second Health and Housing Institute
With historic federal investments in housing and health, states are well poised to shift investments from episodic emergency and institutional care to more sustainable community and supportive housing solutions. Housing stability is an essential social determinant of health and necessary for maintaining positive health outcomes. The impact of COVID-19 on people in institutional settings and populations experiencing homelessness further compels state officials to consider the need for equitable and targeted supportive housing programs. States can leverage federal funding for capital and rental assistance and have a variety of levers including federal Medicaid authorities and Medicaid managed care contracting to address housing-related services.
The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration (HRSA), will convene six states for a two-year Institute beginning in June 2021. NASHP will work with state Medicaid and housing agencies and other state policymakers from six states to address challenges related to sustainable financing of health and housing programs, including ensuring equitable access to housing-related services, demonstrating return on investment (ROI), collecting and sharing data among agencies and providers, determining effective governance structures for cross-sector housing and health initiatives, and measuring program outcomes.
States selected to participate in the Institute include:
- Arizona
- Colorado
- Kansas
- North Dakota
- Pennsylvania
- Virginia
The Institute will draw on lessons learned from NASHP’s first Institute; from November 2018 to November 2020, NASHP convened multi-agency teams in Illinois, Louisiana, New York, Oregon, and Texas. Detailed information on these states’ priorities and outcomes can be found in the final report, Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives.
To learn more about NASHP’s work on health and housing, visit our resource center for states.
Acknowledgement: This project is 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.
Two States’ Approaches to Leveraging Data for Equitable COVID-19 Vaccine Distribution
Federal and state governments are continuing to vaccinate residents as quickly as possible, while working to ensure they reach populations experiencing barriers to vaccination. Access to high-quality data to track and identify under-vaccinated areas and populations is critical to this goal. States have a variety of data systems at their disposal, with vaccine registries at the center.
The National Academy for State Health Policy (NASHP) spoke to state officials in Minnesota and North Carolina, two states who took different approaches to developing COVID-19 immunization data systems, to learn about their experiences, including data challenges, successes, and implications for ensuring an equitable vaccine roll out now and in the future.
Tracking and reporting of COVID-19 vaccine distribution and administration data requires collaboration and integration across various systems that are administering and distributing the vaccine. To collect and track data for the COVID-19 vaccine, states are using their existing immunization information systems (IIS), adopting the CDC’s newly developed Vaccine Administration Management System (VAMS), creating a new system specifically designed for the COVID-19 vaccine, or some combination of these different approaches. The ability to connect IIS with other data sources, like Medicaid claims, and hospitals’ and health systems’ electronic health records (EHRs), is critical to identifying gaps and opportunities for improvement.
In addition to aggregating data across data systems, the completeness of patient records affects efforts to address the gaps. Because Black and LatinX communities have been disproportionately affected by the pandemic, complete patient data, including race and ethnicity data, can help target vaccination outreach to vulnerable communities.
Can you give an overview of the system you use to track and collect COVID-19 specific immunization data?
Minnesota: Minnesota uses an immunization information system (IIS), called Minnesota Immunization Information Connection (MIIC). MIIC-enrolled pharmacists are the only providers who are mandated to collect or upload data into the system. However, all health care staff at provider’s offices can access MIIC, so they have flexibility to input data. And, our health systems are excellent partners that share high quality data to MIIC via the electronic health record (EHR). Additionally, MIIC can capture patients’ vaccine refusal comments and has a reminder/recall function that allows providers to assess which patients are overdue for which vaccine. Minnesota also has data sharing laws that allow schools, childcare providers, purchasers, and community health boards to access MIIC. The ability for schools and childcare providers to review data in the system will be important as children get vaccinated. Our IIS has been working well during the pandemic; we can track and enter data into the system, and it can handle the volume of data without issue. We have been able to onboard new providers expediently and have created a more consolidated process that has been extremely useful.
North Carolina: North Carolina developed the COVID-19 Vaccine Management System (CVMS) instead of using our state’s IIS to create a single end-to-end system for COVID-19 vaccinations. CVMS gives us the ability to add or subtract fields at our discretion. For example, we were able to incorporate North Carolina’s vaccine eligibility determinations and include provider enrollment directly into the system. The system also has the ability to configure to meet provider’s needs, It does not have a reminder/recall system like North Carolina’s Immunization Registry (NCIR). However, CVMS does send proactive e-mail reminders to recipients to get their second doses. CVMS is Version 1 of an iterative software, so all enhancements can be developed in an agile manner.
How are you using data to track areas in need of targeted vaccination approaches?
Minnesota: We have pinpointed a growing list of individuals who have not yet received their second dose. We created this list using our data but have been grappling with how we ensure they actually get vaccinated. One solution we are working to implement is a pilot texting reminder/recall program through a partnership with one of our large health systems and are hoping to make this available more broadly across the state. We have also implemented a change in the data system to allow providers to set parameters to see who in a population needs a vaccine. They will be able to define age parameters and see who in that age bracket has not been vaccinated yet (such as seniors). They can also set product-specific parameters to see who in a county needs a second dose of a specific vaccine and do targeted outreach.
North Carolina: We have geospatial and demographic data for everyone who has received the vaccine, and demographic data and Social Vulnerability Index (SVI) data for all census tracts across the state, so we are able to see where vaccination rates are keeping up with the state average, and which regions are in need of more proactive engagement and partnership.
We are building equity into every aspect of vaccine distribution in order to close the vaccination gap between white populations and Black/African American, Hispanic/Latinx, and American Indian populations in North Carolina, including prioritizing data transparency. We require all vaccine providers to collect and report race and ethnicity data; provide a bi-weekly report to each vaccine provider on their vaccination rates by race and ethnicity; update a public dashboard daily that shows vaccine rates by race and ethnicity at the state and county level, and use this data to inform strategies.
How do COVID-19 immunization data systems interact with EHRs?
Minnesota: MIIC created a unique partnership with the state’s 10 largest EHRs through the EHR consortium. Through partner phone calls, we realized EHR systems collected race/ethnicity and other demographic and comorbidity data while MIIC collected individual patients’ full vaccine history. We partnered to share information across systems to create a full data set. MIIC also gets immunization data directly from the EHRs, which avoids double data entry. And, providers can also query MIIC to get vaccine history and forecast recommendations.
North Carolina: CVMS does not conform with HL7 message structure to exchange immunization information with health systems’ electronic health records and IIS but the platform enables imports of data from EHRs using a standardized file format, which prevents the need for double data entry. We are developing a system that will be able to push the COVID-19 vaccine data into the state IIS, which is critical to having one source of vaccine data for providers, schools, etc. The state IIS is also connected to EHRs, and allows providers that have been onboarded to check for vaccine status through the EHRs.
What are some challenges you have seen in accurately identifying areas of need?
Minnesota: Previously, vaccine supply and inconsistency with delivery had been an external factor that created challenges to accurately identify areas of need, though this is less of an issue now given more consistent supply. In terms of data, because we do not have a mandate to enter data into the IIS, we accept many different types of data, and we have heard from individuals that it has been a barrier to use full-scale EHRs in vaccine clinics because of the technology hurdles.
North Carolina: When supply was more limited, we set aside doses for vaccine providers and events focused on historically marginalized populations (HMP) and relied upon provider data of vaccinating these populations to determine allocation strategy. We track equity gaps – i.e., the difference between HMP vaccination rates and proportion of population – at the provider type, county, and individual provider level, and we share this information back with vaccine providers. We found that equity gaps have steadily declined across geographies as a result of this and other equity-focused vaccination strategies. External barriers like internet access, limited interpretation services, and transportation have also created challenges in ensuring access to vaccinations. We have invested in strategies for people to access information without having to go online – i.e., set up a call center with English- and Spanish-speaking agents who can answer common vaccine questions and help people find vaccine providers near them. We also have had to make it clear up front that identification and insurance are not required, and that data collection relies on self-attestation.
What are some “best data practices” you have found to ensure an equitable distribution of the vaccine?
Minnesota: We use data from MIIC to look at vaccine uptake by SVI. A Federal Emergency Management Agency (FEMA) site was placed in St. Paul which targets zip codes with high SVI. FEMA sites can distribute a small percentage of their allocated vaccine doses off-site, and have utilized some mobile vaccinations for the distribution processes.
North Carolina: We regularly review provider race and ethnicity data internally to evaluate progress and share externally. We promote accountability through data transparency and use of data; we share bi-weekly reports to vaccine providers on their race/ethnicity and publish public dashboards that are updated daily with vaccine rates by race/ethnicity at the state and county levels. We use the data to identify census tracts with high SVI and low vaccination coverage to recruit and allocate to new providers and inform micro-targeting of related resources, such as public communications/media or the support of community health workers. Our data platform is also flexible; it is able to handle new requirements over time.
How have you used federal funding to enhance your data capabilities and ensure full vaccination coverage?
Minnesota: We have a cooperative agreement through the CDC on the business and operational side of the IIS and technical funding comes from the HITECH 90/10 match. We used our previous funding to implement the reminder/recall function, as well as other IIS enhancements, like a COVID-19 assessment report, that will be available soon, improvements to geocoding, implementing COVID-19 vaccine ordering in MIIC, and automating our reporting to the CDC.
North Carolina: We fund CVMS through a variety of funding sources, but primarily through the CARES Act Coronavirus Relief funds. We plan to use American Rescue Plan Act (ARPA) funding to support continued vaccine implementation efforts, including strategies that ensure greater equity and access to the COVID-19 vaccine by those disproportionately affected by COVID-19. The new ARPA funding will also be used to support local communities through local health departments, community-based organizations, and current community vendors to provide mobile vaccination. In addition, we are planning to sponsor vendors to go into neighborhoods to provide vaccine education and administer vaccines to historically marginalized populations that have had challenges accessing vaccines.
What lessons have you learned from the pandemic that you will be able to use to improve vaccination rates (both for COVID-19 and for routine immunizations) moving forward?
Minnesota: There continues to be concern around the gap in childhood immunization rates that has developed as the result of children missing primary care visits, and the MN Immunization program is in the process of determing the best method to help close those gaps. In general, we’ve had new funding conversations that could not have happened without our strong partnerships with health systems and are hoping these partnerships will have built a foundation for immunizations that we can continue past the pandemic.
North Carolina: As we move from very limited supply to increased volume, our approach to using data to achieve vaccine equity is evolving. Moving forward, we are focusing even more intently on census tracts with low vaccination rates and high social vulnerability to determine tailored strategies for identifying providers (including state-sponsored vendors) who can vaccinate in those census tracts, paired with trusted community partners and community health workers to optimally establish mobile or fixed vaccination sites. It can be tricky to balance data sharing and transparency with the critical requirement (and value) of preserving privacy, but it is possible. Overall, our team has learned to be flexible and to openly communicate within the team and with partners.
Acknowledgements: This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
Promoting Maternal and Child Health: Virginia’s Dental Benefit for Pregnant Women
The maternal mortality crisis has driven state and federal leaders to address access to high quality care during the perinatal period. With proposals to extend Medicaid coverage to twelve months postpartum, states are also considering what services are offered to pregnant women through Medicaid. Currently, 29 states and Washington DC offer extensive dental services to pregnant and postpartum women.
Dental care during the perinatal period influences health outcomes for both the parent and child, and can reduce expensive medical care that results from lack of care. With this in mind, Virginia added a pregnancy dental benefit in 2015. With nearly half of pregnancies in the United States financed by Medicaid, Virginia shows how states can play an important role in providing access to dental care for pregnant women through their Medicaid programs.
Access to Perinatal Dental Care and Health Outcomes
Inability to access dental care while pregnant can result in adverse health outcomes. Research indicates that all dental care, including procedures that require dental anesthesia during pregnancy, is safe. Poor oral health is associated with low birthweight, preeclampsia, other pregnancy complications and a lower quality of life. Nationally, 73 percent of women had dental insurance during pregnancy, but only 48 percent received a dental cleaning during pregnancy.
Evidence suggests that prenatal oral health care can improve children’s oral health by reducing the incidence of Early Childhood Caries (ECC). ECC is the presence of decayed, missing or filled tooth surfaces in primary (baby) teeth in a child under the age of 6. ECC can lead to emergency room visits and negatively impact school performance. Dental caries (tooth decay) is the most common chronic disease in US children ages 6 to 19 years. Additionally, children are at a higher risk for tooth decay if their birth parent has untreated tooth decay. Parents’ oral health behaviors and dental care utilization can influence children’s risk of dental caries.
Despite overall oral health improvement in the United States over the past several decades, racial and economic disparities persist. Access to dental clinics, insurance status, financial resources and underrepresentation of people of color in the dental workforce are cited as structural barriers for accessing dental care for people of color. These disparities are evident in children, pregnant women and adult populations:
- Latino children, regardless of insurance type, visit the dentist less frequently than white children and are more likely from age two to five have cavities.
- Black and Hispanic pregnant women are less likely to receive dental care, including teeth cleanings before or during pregnancy, than white women.
- Over 40 percent of low-income and non-Hispanic Black adults experience tooth decay, and low-income adults are three times as likely to have four or more untreated cavities as adults with higher incomes.
Dental Care for Pregnant Women in Medicaid
While state Medicaid programs are required to cover dental services for children under 21 as a part of the Early and Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit, dental services for adults are optional in Medicaid. However, 36 states and Washington, DC provide services beyond emergency dental situations; 22 states and Washington, DC provide extensive services for adults, and 29 states and Washington, DC offer an extensive benefit to pregnant women. State benefit packages vary from state to state and generally fall into the following categories:
- Emergency services only;
- Limited services: a cap of $1,000 annually and fewer than 100 American Dental Association (ADA) identified services; or
- Extensive coverage: a cap greater than $1,000 dollars annually and more than 100 ADA identified services including major restorative procedures.
The American Academy of Pediatric Dentistry and the American College of Obstetricians and Gynecologists recommend diagnostic, preventative, restorative, emergency and periodontal care for pregnant women.
When states face revenue shortfalls, they tend to cut optional services, including dental services for pregnant women. For example, 19 states restricted their dental programs during the great recession and only 8 states restored their dental benefit between state fiscal years 2013 and 2016. Despite these fiscal constraints, Virginia expanded health benefits to pregnant women, citing the importance of good oral health for overall health and impact on child oral health.
Virginia’s Dental Benefit for Pregnant Women
Recognizing the importance of oral health in overall health and its key role in healthy birth outcomes, Virginia added a dental benefit in 2015. It was introduced as part of Gov. McAuliffe’s A Healthy Virginia Plan, which proposed expanding services to over 200,000 Virginians, including dental benefits to 45,000 pregnant women in Virginia. The initial cost for the program was 1.9 million over the 2014-2016 biennium budget.
In Virginia, pregnant women over age 21 with incomes less than 148 percent of the Federal Poverty Line (FPL) are covered by Medicaid, and pregnant women with incomes between 148 and 205 percent FPL are covered by the Family Access to Medical Insurance Security (FAMIS) program, which is Virginia’s Children’s Health Insurance Program (CHIP). Dental services are delivered either by the individual’s selected medical managed care organization (MCO) or through fee-for-service. All pregnant women receive dental services through the state’s Smiles For Children program, provided by a dental benefits manager (DBM). The dental benefit ends at the end of the month following an individual’s 60th day postpartum.
Virginia requires coordination between the Medicaid MCOs and the DBM. The Medicaid managed care request for proposals (RFP) outlines the MCO’s role for coordination with the DBM on outreach for dental service utilization. According to state officials, the Commonwealth has also established relationships between MCOs and the DBM to assist pregnant members in locating dentists and securing appointments.
State officials noted that there is still skepticism about going to the dentist while pregnant. This presents the state with an opportunity to collaborate with MCOs and the DBM to educate enrollees about the safety of services and the new benefit.
A staff member with the DBM is responsible for collaboration efforts including education and training. Virginia Medicaid MCOs work to promote dental services with pedicitricians, family practices and OB/GYNS through the Smiling Stork Program. The Smiling Stork program educates women about the importance of being screened for periodontal disease during pregnancy, the value of establishing good oral health habits for their babies, and how to access covered dental services during pregnancy.
The addition of dental services for pregnant women in Medicaid has yielded positive results for Virginia. Pregnancy Risk Assessment Monitoring System (PRAMS) data show that the number of pregnant women receiving dental services doubled from 2014 to 2019. The Virginia Department of Health created practice guidance for prenatal and dental providers, and it conducts outreach to maternity clinics to promote dental care access.
The expanded dental benefit was initially funded for three years. The Department of Medical Asssistance Services (DMAS), Virginia’s Medicaid program, engaged the Dental Advisory Committee and other stakeholders to maintain the expanded benefit. State officials cite strong internal collaboration among IT staff, health care services, maternal and child health, training and transportation, and executive leadership as key for successful implementation of the benefit.
Implications
Recent state Medicaid coverage expansions and a concerted focus on improving maternal health provide opportunities for states to ensure dental services for pregnant women. The expansion of dental services for pregnant women in Virginia was a part of broader coverage expansion introduced by Gov. McAuliffe, with the 2015 dental benefit for pregnant women predating Medicaid expansion in 2019 and an adult Medicaid dental benefit in 2020.
Virginia also recently submitted an amendment to its 1115 demonstration waiver to extend postpartum Medicaid coverage to 12 months. This expansion would include dental benefits, as “full benefit coverage is essential to meeting the needs of the state’s postpartum women.” The demonstration waiver amendment includes an evaluation plan to determine the impact of postpartum coverage on reducing the rate of maternal mortality, morbidity and racial disparities among postpartum women and infants.
As Virginia expands services for pregnant and postpartum women, there is an increased focus on quality care during the perinatal period at the state and federal level. The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act introduced in the House of Representatives and Senate would extend Medicaid coverage to 12 months postpartum and require states to cover preventative, diagnostic, periodontal and restorative care during pregnancy and the postpartum period. Additionally, the recently passed American Rescue Plan gives states the option to extend Medicaid coverage to 12 months postpartum through a state plan amendment (SPA). States seeking to expand postpartum coverage through a waiver may select the SPA option.
Another introduced bill, S. 560, the Oral Health for Moms Act, aims to expand dental services for pregnant women. This bill would require Medicaid and CHIP to cover dental services for pregnant and postpartum women and make dental services an essential health benefit for pregnant women who receive health insurance through the federal marketplace or small group markets. The bill would also:
- Provide grants to federally qualified health centers (FQHCs) for dental services;
- Create an oral health initiative through the Indian Health Service to address barriers to oral health for American Indian and Alaskan Native populations;
- Require the Medicaid and CHIP Payment and Access Commission to issue a maternal oral health care report;
- Establish a perinatal oral health outreach and education program to provide information on best oral health practices and connect pregnant and postpartum individuals and children to oral health care; and
- Integrate oral health care into maternal health care settings through grants to state health departments and agencies to develop trainings on oral health for maternal health providers.
With national attention on Medicaid coverage for the postpartum period, states can consider including dental services as a component of perinatal health care. New federal options including the MOMMA’s Act, ARPA, and Senate Bill 560 may allow states to expand dental services to pregnant women and lengthen the duration of services; recently introduced federal legislation might further increase opportunities for states. Experience from Virginia can serve as a case study for states looking to expand access to dental services during the perinatal period and improve maternal health outcomes.
Acknowledgement: This project is 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. The author would like to thank the Virginia state officials, including Dr. Hairston who helped review and provide feedback on this blog.
Trish Riley, Signing Off
My career in state government and at NASHP has provided me an extraordinary opportunity to work with some of the smartest, most hardworking people, dedicated to public service and advancing efforts to improve the public’s health and assure affordable, quality health coverage. It is almost hackneyed to cite Justice Brandeis’ characterization of states as the laboratories, trying novel social and economic experiments. But in healthcare that is clearly true – states created children’s health coverage; built home care options to nursing facilities, enacted insurance rate reforms and subsidized coverage, mandated mental health parity, eliminated pharmacy gag clauses, launched prescription drug affordability boards, established a public option and so much more before the federal government acted. States are raging incrementalists, pushing for important health care reforms and informing federal action. I am humbled to have been engaged in so many of these efforts.
Public service has been, for me, a noble profession, working close to the ground trying to get policy and practice right to respond appropriately to human need and opportunity. I have split my career, working under five Maine Governors and building NASHP. As a state official, each day I went to work I knew the woman who poured the coffee at Dunkin’, the small businesses like the dry cleaner and the gas station, the workers who scraped by on low wages were paying the taxes that supported my job and the programs we created and ran. That compelled my fiscal conservatism and an urgency to make sure everybody could be as healthy as possible and to afford health coverage and long-term services and supports. That seems to me to be a key part of government’s responsibility – our commitment to care for each other and the common good.
But that work is tough – like Sisyphus pushing the rock up the hill, states keep pushing, even as that rock rolls back. Progress is often slow and hard, but progress has been the watchword of states. Outside of state service, the opportunity to build NASHP as a safe harbor for busy state leaders and a place to provide them the resources and support they need to get that rock over the hill has been a particular joy. NASHP’s mission to work across the usual lines of organizational authority and to bring legislative and executive leaders together to contemplate and craft solutions to the complex issues they face remains an important one. And NASHP’s commitment to be “of states, by states and for states” has meant for me the chance to brainstorm with some truly remarkable leaders and engage a great staff as NASHP set its course.
I take my leave now as NASHP is stronger than ever, thanks to the enduring support of our funders, but as the times make our work more challenging. Beyond the current crisis, there is another pandemic in which increasingly policy takes a back seat to politics and ideology. Anecdote replaces evidence and harsh, bright lines are drawn making it harder to find the middle. A quotation attributed to Margaret Thatcher – not someone I would think to quote – seems relevant again today – “It used to be about trying to do something. Now its about trying to be someone.”
Since its inception in the late 1980’s, NASHP has been a place for the “do-ers” and there is so much left to do. The pandemic’s stark revelation of continued social and economic inequities, the appalling statistics showing health costs still so high and health outcomes still low, cry out for states to lead again, providing the bold experimentation that Justice Brandeis envisioned. I am confident that NASHP with its creative state leaders, dedicated staff, engaged board of directors and new executive director Hemi Tewarson, will help states lead the way. I am retiring from the job but not the fight and look forward to cheering you on and finding new ways to remain a “do-er”. Thank you all for the phenomenal opportunities and friendships in our pursuits.
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. 
