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Eligibility Levels for Pregnancy-Related Coverage in Medicaid and CHIP
Eligibility Levels for Pregnancy-Related Coverage in Medicaid and CHIP
State Health Policy Resources to Promote Black Maternal Health and Equity
Each year approximately 700 women die in the United States as a result of pregnancy or related complications, and Black women are more than three times more likely to die in childbirth than White women. Each year, the Black Mamas Matter Alliance sponsors a Black Maternal Health week (BMHW) on April 11-17.
In 2021, President Biden signed a proclamation recognizing BMHW and “the importance of addressing the crisis of Black maternal mortality and morbidity in this country.” The proclamation states the Biden Administration is committed to pursuing systemic policies, like addressing social determinants of health to reduce maternal mortality.
The National Academy for State Health Policy (NASHP) currently operates a state policy academy to support states in improving maternal health outcomes, with a specific focus on reducing racial disparities in maternal mortality. The following are examples of actions states are taking to reduce maternal mortality among Black women:
- Maternal Mortality Review Committees (MMRC). Review of maternal deaths is vital to inform prevention efforts. Nearly all states have an MMRC, but Committees differ by membership, scope of work and recommendations. Examining deaths by race and ethnicity through a full year postpartum can also help identify drivers of maternal mortality disparities. For example, a review of 14 Maternal Mortality Review Committee reports found that the leading cause of death for non-Hispanic White women was behavioral health conditions (including mental health, substance use disorder and overdose) while the leading cause for non-Hispanic Black women was cardiovascular-related conditions. Understanding the root causes of these deaths can inform recommendations to reduce disparities.
- Postpartum Coverage Extension in Medicaid. Some states are pursuing options to extend coverage to 12 months postpartum for pregnant people. Section 9812 of the American Rescue Plan Act provides states the opportunity for continuous Medicaid coverage through 12 months postpartum. As Medicaid pays for 65 percent of births for Black women, extending Medicaid coverage has the ability to greatly improve health outcomes and reduce racial disparities.
- Medicaid Coverage of Doula Services. Doulas provide culturally congruent physical, psychological and emotional care over the perinatal period and can make important connections to care and social services in communities. Currently four states (Minnesota, New Jersey, Oregon and Virginia) reimburse doulas as an optional Medicaid benefit. Pregnant people who receive doula care are more likely to have a healthy birth outcome and positive birth experience. Community-based doula programs engage trusted community members and can support Black mothers with shared decision making and self-advocacy. Medicaid reimbursement for doula services can increase access and birth outcomes for Black women.
Recently released data by the National Center for Health Statics, shows the number of women who died during pregnancy or 42 days after termination or pregnancy increased 14 percent from 2019 to 2020, with significant increases for non-Hispanic Black and Hispanic women. These data highlight the importance of considering state policy options to reduce racial disparities and promote wellbeing across the perinatal period. NASHP will continue to work with states and track state action to improve maternal health outcomes.
Below are state health policy resources to promote Black maternal health equity.
Doulas
- State Medicaid Approaches to Doula Service Benefits, March 2022
- Virginia Invests in Doulas to Improve Maternal Health Outcomes, February 2022
- Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid, July 2020
Health Equity
- Virginia Advances Maternal Health Equity Policy, October 2021
- Resources for States to Address Health Equity and Disparities
Home Visiting
Maternal Mortality
- State Maternal Mortality Review Committees Address Substance Use Disorder and Mental Health to Improve Maternal Health, August 2021
- State Maternal Mortality Review Committee Membership and Recommendations, February 2021
Postpartum Coverage
Behavioral Health
Washington Joins Leading States in Establishing a Prescription Drug Affordability Board
On March 24, 2022, Washington state joined five other leading states in establishing a Prescription Drug Affordability Board (PDAB) when Governor Inslee signed SB 5532, sponsored by Senator Karen Keiser, into law. Washington’s PDAB, like those already established in Maryland and Colorado, has the authority to limit what payers in the state will pay for certain high-cost drugs following an affordability review.
Because Washington state enacted a prescription drug price transparency law in 2019 (HB 1224) and has an all-payer claims database, the state is well positioned to identify the costly drugs that the PDAB may consider for an affordability review, the first step toward establishing an upper payment limit for state payers. The Board’s work will focus on the costliest drugs: brand name drugs costing more than $60,000 a year or with price increases of 15% or more over the past year, or 50% in the past three years. Biosimilars and generics are also included under specific circumstances. The Board must identify drugs for an affordability review by June 2023 but may not establish an upper payment limit before January 1, 2027. At that time, the Board may set upper payment limits for up to 12 drugs a year.
This session, Washington state also extended a law capping out-of-pocket insulin costs through 2024. The new law also lowered the insulin cap from $100 to $35 a month. In the meantime, the state’s Total Cost of Insulin Work Group plans to convene to identify and pursue strategies to lower the cost of insulin in the state.
More than a dozen states have enacted legislation to cap out-of-pocket costs for insulin and on March 30, 2022, the House passed a federal out-of-pocket cap for insulin at $35 a month (HR 6833). While out-of-pocket caps bring necessary and immediate relief to consumers, additional measures like a state PDAB or federal drug price negotiations, are also necessary to lower the total cost of the drugs for payers.
The National Academy for State Health Policy (NASHP) is tracking more than 250 state bills aimed at lowering drug prices during the short 2022 legislative session. While most of those bills continue to be efforts aimed at regulating pharmacy benefit managers, the middlemen who negotiate rebates with drug manufacturers and pay pharmacy claims on behalf of health plans, there is growing momentum around PDABs. Nine states have 13 PDAB bills this session. Several other states, – including Rhode Island, Maine, Hawaii, and North Carolina – have introduced bills to achieve savings by referencing Canadian drug prices to establish payment rates for state payers. Those bills reflect model legislation released by NASHP in 2020, An Act to Reduce Prescription Drug Costs Using International Pricing.
Understanding Hospital Costs— New Tool Makes Data More Transparent and Accessible
Data will be critical to informing effective cost-containment policy options for states.
Washington DC—Hospitals provide critical care for many consumers across the states. However, as health care spending continues to rise for consumers and payers—with the largest proportion of those expenditures on hospital services—states and other purchasers are seeking to better understand and address hospitals’ costs. Even with increased hospital transparency requirements, it is unclear how hospital prices relate to the expenses hospitals incur to provide services. The National Academy for State Health Policy (NASHP) in partnership with the Rice University Baker Institute for Public Policy and Mathematica Policy Research, with support from Arnold Ventures, has developed the Hospital Cost Tool (HCT) to help shed some light on this issue.
The HCT identifies different cost measures including hospital revenue, cost to charge ratios, and profitability across more than 4,600 hospitals nationwide from 2011 through 2019. It is interactive, allowing users to examine data for an individual hospital or specific health system, by state or users can compare data across hospitals and states. The tool is based on NASHP’s Hospital Cost Calculator that uses Medicare Cost Report data annually submitted to the federal government by hospitals. Data for 2020 will be added to the tool after more hospitals have completed their reports for that year.
“This new tool provides a view of publicly reported hospital data that isn’t otherwise available to policymakers and purchasers,” says Hemi Tewarson, NASHP’s Executive Director. “NASHP’s tool is an important resource for understanding costs of individual hospital and health systems—a critical first step to thoughtfully addressing rising health care costs.”
One notable metric within the HCT is hospitals’ breakeven point, which is the amount a commercial health plan would need to reimburse a hospital to cover its expenses. In calculating the breakeven, the tool accounts for a hospital’s operating costs, profit or loss from public coverage programs, charity care and uninsured patient hospital costs, Medicare disallowed costs, and a hospitals other income and expense. Purchasers of care, including states and employers, can compare the breakeven point to the data point showing what commercial payers pay. Depending on the hospital, the breakeven point and what commercial payers reimburse can be significantly different, indicating an opportunity to renegotiate payment rates.
“Understanding a hospitals’ breakeven point allows a purchaser like a state, an employer, or a health plan to negotiate a payment that offers an increase from the hospital’s costs rather than a discount from the hospital chargemaster, which is how most payment rate discussions start,” said Marilyn Bartlett, Senior Fellow at NASHP and former Administrator of the Montana State Employee Health Plan. Bartlett led the development of the HCT and conceptualized and used the breakeven calculations in Montana’s successful efforts to move its state employee plan to reference-based purchasing, saving millions of dollars.
Several employer purchasing coalitions have already begun using data from the HCT to help differentiate charges from costs to leverage the information in payment negotiations. A growing number of states are also using the data to develop strategies that address high costs in order to provide effective cost-containment policy options.
“Peak Health Alliance has used the NASHP hospital cost tool extensively and credits a good bit of the millions of dollars we have saved our members to the insight it provides. This tool helped us go from conceptually recognizing how important it is to understand a hospital’s finances to having practical hands-on knowledge that informs our negotiations and ensures a fair and reasonable agreement. It has really leveled the playing field between Peak and our hospitals,” said Claire V. S. Brockbank, Chief Executive Officer of Colorado’s Peak Alliance.
Jane Beyer, Senior Policy Advisor in the Office of the Washington Insurance Commissioner and the Chair of NASHP’s State Academy said, “Addressing rising health costs is necessary but is complicated and one-size does not fit all. States with urban centers and vast rural areas; with large health systems and small to mid-sized independent hospitals, need individualized hospital financial information to develop and implement data-driven policies. NASHP’s tool that allows examination of multiple variables by hospital bed size or of hospitals in one health system that cross multiple states, is critical to designing meaningful policies.”
NASHP is hosting a demonstration (for press only) of the Hospital Cost Tool with Marilyn Bartlett this Thursday, April 7 at 1:00 pm ET. Register for more details.
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.
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. 
