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Establishing a Chief Equity, Inclusion and Opportunity Officer in Indiana
In November 2020, Governor Holcomb appointed Karrah Herring as Indiana’s first Chief Equity, Inclusion and Opportunity Officer (CEIOO). This position supports agencies across Indiana government to “build diversity and foster an inclusive environment.” Indiana joins a growing list of states, including Illinois, Michigan, New Jersey, Oregon, and Virginia, in committing to principles of equity and inclusion in their whole-of-government approach. Karrah Herring and Jennifer Sullivan, Former Secretary of Indiana’s Family and Social Services Administration (FSSA), recently spoke to the National Academy of State Health Policy’s Equity Workgroup about Herring’s role. Chief Officer Herring also presented at the NASHP annual conference in September 2021 and shared insights on Indiana’s journey in establishing this position and next steps in Indiana.
Background
Following the murder of George Floyd and the racial disparities illuminated by COVID-19, Governor Holcomb delivered an address on equity and inclusion in Indiana in August 2020. In his speech, Governor Holcomb discussed the common theme of “getting to the root causes of inequities and not just reacting to the symptoms” in his meetings with rural, urban, and suburban citizens across the state.
Two months before his address, Governor Holcomb formed an Executive Branch Task Force to identify gaps in state government and recommend actions to address disparities and inequities. The first action, identified in his address, was to create Indiana’s first Chief Equity, Inclusion and Opportunity Officer position to:
- “focus solely on improving equity, inclusion and opportunity across all state government operations as well as drive systemic change to remove hurdles in the government workplace and services we provide, and
- help them develop their own strategic plans to tactically remove all such barriers.”
Governor Holcomb identified other areas to address racial inequity and promote equal opportunity in the state. These initiatives include improving minority teacher recruitment, investing in Indiana’s workforce to fill job openings, mandating the use of body cameras for every state trooper, and a review of curriculum and training for the law enforcement academy. He also vowed to create a public disparity data portal to track progress towards health, public safety, social services, education, and workforce goals.
Indiana’s Family and Social Services Administration
Prior to Governor Holcomb’s address on equity, Indiana’s Family and Social Services Administration (FSSA) had begun to systematically address the social drivers of health, including the role of structural racism in overall well-being of Hoosiers. In 2018, Indiana FSSA created the Office of Healthy Opportunities to build out an integrated health and human services approach to address social determinants of health. The office implemented a data-driven strategy to identify both unmet social needs in the state and gaps in policies and programming, and subsequently launched an educational campaign for FSSA employees on social determinants of health and health disparities. In his address on equity, Governor Holcomb cited recent success in his priority to reduce infant mortality as the model for his approach to advancing equal opportunity, as Black women and children are disproportionately affected by infant mortality due to systemic barriers.
To help FSSA work to understand unmet social needs, Secretary Sullivan explained that it was necessary to identify structural barriers to care. This work culminated in the creation of the FSSA Equity Blueprint. The Blueprint contains important recommendations for the agency, including the creation of a Chief Health Equity and Americans with Disabilities Act (ADA) Officer for the FSSA agency. FSSA also recommended a cabinet level Chief Equity Inclusion and Opportunity Officer position to report to the Governor.
Chief Equity, Inclusion and Opportunity Officer
A team including Secretary Sullivan wrote the Chief Equity, Inclusion and Opportunity Officer position description. The position is funded through a public-private partnership with a financial contribution from the CenterPoint Energy Foundation. The Officer is a member of the Governor’s cabinet and reports directly to Governor Holcomb. Governor Holcomb’s office stated, “the officer will focus on improving state government operations as well as drive systemic change to remove hurdles in the government workplace and services the state provides. Herring will help agencies develop strategic plans to remove any barriers.”
Herring was appointed in November 2020 and started in the position in February 2021. In the first six months of her tenure, she met with over 200 stakeholders including mayors, community leaders, and chambers of commerce to better understand what equity looks like in different communities. According to Herring, contributors vary across the state; in rural Indiana inequities may be rooted in access to broadband while other parts of the state face high infant mortality rates, for example.
In response to Governor Holcomb’s goals for addressing equity, Herring’s office created an Equity Data Portal that tracks state efforts on closing equity gaps. Indiana’s Management Performance Hub worked with state agencies to create the portal that provides data dashboards on health, public safety, social services, education, and workforce. Herring emphasized that the data portal will drive her office’s strategy and outcome measures will be used to show the effectiveness of resources deployed toward strategic priorities.
Indiana’s COVID-19 Response
Herring’s office also played a key role in Indiana’s COVID-19 response, connecting Indiana’s Department of Health with key diverse stakeholders such as the Urban League, National Association for the Advancement of Colored People (NAACP) and other organizations serving communities of color. The state used data on vaccine uptake and the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) to target vaccine outreach. According to Herring, each Indiana county was given an odds ratio based on gender, race, and age. In Gary, Indiana, low vaccine uptake and a high SVI led to the state partnering with the Federal Emergency Management Agency (FEMA) on an eight-week mass vaccination clinic that led to over 60,000 vaccinations. The state also created a messaging toolkit for providers to counsel patients about the COVID-19 vaccine.
Working with Organizations and Agencies on Diversity, Equity, and Inclusion (DEI) Initiatives
Following her conversations with organizations and agencies, Herring developed a DEI strategic communications toolkit, which she shared at a summit she hosted for DEI leaders from across the state. When asked, Herring has shared the toolkit with Chambers of Commerce and Boards of Directors across the state to guide their DEI efforts. The toolkit has also been shared internally with state agencies. The toolkit encourages organizations to:
- Define DEI for the organization. Consider how each organizations’ existing mission, vision and foundational values align with DEI.
- Start with civility and respect. Everyone enters the DEI space along a continuum and the State of Indiana Workforce’s goal is to meet people where they are through civility, constructive disagreement, and compassionate listening. Inclusive language can allow for more productive dialogues. The Office of the Chief Equity Inclusion and Opportunity Officer (CEIOO) offers a Supporting Next Level TEAMS training to prepare teams for “more in-depth discussions on equity, bias, consciousness, and allyship.”
The CEIOO office’s communications toolkit also outlines the importance of leadership buy-in and making the case to see DEI efforts incorporated into organizational culture and values. Key tactics include:
- Start with the data. Disaggregating available data points such as workforce by job level and classification, recruiting efforts, hiring data, promotions, and turnover can reveal organizational inequities and make the case for a DEI strategy.
- Define organizational needs. Tailor a DEI approach to the culture and needs of the organization.
- Go after low-hanging fruit. Implementing inexpensive efforts like monthly DEI talks, employee resource groups, or a calendar of cultural events can demonstrate organizational commitment early.
- Demonstrate return on investment. Show how staffing and financial resources can yield financial returns. Expanding recruiting to diversify applicant pools is an inexpensive practice to diversify teams. Companies that embrace diversity and inclusion report a culture of innovation, higher engagement, lower turnover, and increased profits.
Moving Forward
In September 2021, Herring joined NASHP’s annual conference to discuss her work as Indiana’s first Chief Equity, Inclusion and Opportunity Officer. She was joined by Dr. Janice Underwood, Virginia’s Chief Diversity, Equity and Inclusion Officer, and Michigan’s Lt. Gov. Garlin Gilchrist II, who is leading Michigan’s work on racism as a public health crisis. During the session, Herring credited Dr. Underwood for her guidance during the creation of Indiana’s office. She emphasized the importance of codifying the position so that Indiana’s equity work can continue as a whole-of-government approach past the current administration.
In Indiana and other states, significant resources were deployed to increase vaccination rates among communities of color. Herring proposed that the same investment needs to be strategically focused on issues affecting Indiana’s population such as maternal and infant mortality, preterm birth, access to proactive health screenings, and social determinants of health. She stressed the importance of a data driven approach, and that solutions to address challenges faced by communities of color are not one size fits all. She noted that her office will be examining equity through the lens of workforce, economic, and community development. In her closing remarks, Herring said “maybe we won’t need Chief Equity Officers in 30 years, but right now we do.”
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation. The author would like to thank Chief Officer Herring for her presentation to NASHP’s equity workgroup, her participation in the NASHP annual conference and review of this publication.
NASHP’s Annual Conference Highlights States Taking Bold Action on Drug Prices
While Congress continues to consider significant reforms for drug pricing, states have taken bold steps to control drug prices across payers. This legislative session, Colorado followed Maryland’s lead and established a prescription drug affordability board (PDAB) to address high drug prices. PDAB legislation, such as Maryland’s and Colorado’s, that includes authority for a board to set upper payment limits (UPLs) within a state for high cost drugs, represents some of the strongest state efforts to date to rein in drug costs. The National Academy for State Health Policy’s (NASHP) 2021 annual conference featured a session highlighting Colorado and Maryland’s PDAB laws, as well as New York’s experience with enhanced negotiating authority with manufacturers for high cost drugs within its Medicaid program. New York’s success in achieving notable savings offers insights on implementation that can help guide states standing up PDABs.
Maryland’s Prescription Drug Affordability Board
Enacted in 2019, Maryland’s PDAB law was created to study the prescription drug market in Maryland and to protect consumers and the state from the high costs of prescription drugs. The Board has spent the past year analyzing Maryland’s pharmaceutical distribution and payment system and will report findings, along with policy options to lower costs, to the General Assembly by the end of this year. In September, Maryland issued its first round of invoices for the assessment on drug manufacturers and other entities along the supply chain to support the work of the state’s PDAB. Under the legislation, the PDAB can consider setting upper payment limits, implementing a reverse auction marketplace, and establishing a bulk purchasing process. If the Board determines it is in the interest of the state to establish a process for setting UPLs, the Board must create a plan of action for implementing the process that includes the criteria the Board shall use to set UPLs and submit the plan to the Legislative Policy Committee for its approval. If the plan is approved, the Board may begin setting UPLs for state purchasers in 2022, and for all purchasers starting in 2023.
Colorado’s Prescription Drug Affordability Board
In June 2021, lawmakers in Colorado enacted a law to create a PDAB with aggressive timelines that will enable the Board to begin setting upper payment limits for all payers as early as next year. The law has a transparency component that requires insurance carriers and pharmacy benefit managers to report certain cost and utilization information to the Division of Insurance. The Board will use that data to perform affordability reviews of drugs that exceed the wholesale acquisition cost triggers outlined in the law.
Beginning April 1, 2022, the Colorado PDAB may establish UPLs for up to 12 drugs each year. Colorado’s PDAB, unlike Maryland’s, does not require additional legislative authority to set UPLs, and UPLs will apply to all purchases of and payer reimbursements for a drug dispensed or administered in the state. Similar to Maryland, the Colorado PDAB will make policy recommendations to the General Assembly on strategies to improve the affordability of prescription drugs for consumers.
New York Medicaid’s Drug Cost Cap and Enhanced Negotiating Authority in Massachusetts
In 2017, New York enacted a law that gave the Medicaid program the authority to negotiate with drug companies for supplemental rebates if drug spending is projected to exceed an annual spending limit, which is based on a 10-year rolling average of the Consumer Price Index. If the state is unable to reach an agreement with a manufacturer, a drug may be referred to the Drug Utilization Review Board (DURB), which then conducts a value assessment of the product. When conducting a value assessment, the DURB can consider a drug’s affordability and net cost to Medicaid, value-based pricing, significant price increases, and/or the proportionality of price to therapeutic benefit.
Five years later, New York has had success with this approach. Since the law went into effect in 2018, the state has negotiated over 50 new supplemental rebate contracts with manufacturers, which have generated over $500 million in new supplemental rebates. The DURB has also completed three value assessments for the drugs Orkambi, Remicade, and Spinraza. The DURB used value-based pricing benchmarks from the Institute for Clinical and Economic Review (ICER) to guide the Department of Health on target supplemental rebate amounts for Orkambi and Spinraza and a domestic reference pricing approach for Remicade because two comparable biosimilars were on the market. As a result, New York’s drug cap is achieving additional rebates and reducing the growth of spending without limiting access to high-cost drugs.
Massachusetts has a program similar to New York’s which enables enhanced negotiating authority within its Medicaid program. If an agreement cannot be reached and the drug exceeds certain price thresholds, the drug can be referred to the Massachusetts Health Policy Commission (HPC) for review. To date, this approach has been successful in securing additional rebates without the need for HPC review.
For more information about state actions to lower drug costs, explore NASHP’s Comparison of State Prescription Drug Affordability Review Initiatives and legislative tracker.
Resources to Help States Improve Maternal and Infant Health
The Biden-Harris Administration continues to make investments in improving maternal and child health. The Department of Health and Human Services (HHS) recently announced a $350 million dollar investment to support safe pregnancies and babies. Funding, distributed through the Health Resources and Services Administration (HRSA), supports home visiting services for families, community doulas, data infrastructure, and infant health equity.
Explore the resources on this page to learn more about states’ efforts to improve maternal and infant health.
Home Visiting
- State Medicaid Financing of Home Visiting Services in Seven States
- Medicaid Financing of Home Visiting Services for Women, Children, and Their Families
- Public Insurance Financing of Home Visiting Services: Insights from a Federal/State Discussion
Doulas
Investments in Behavioral Health Service Systems: Top Three Emerging Themes from State Home and Community-Based Services Spending Plans
States, taking advantage of federal flexibilities and new federal funding, are implementing policy changes that seek to increase availability of and equitable access to behavioral health services. In anticipation of the one-year, 10% increase in the federal medical assistance percentages (FMAP), provided by the American Rescue Plan Act (ARPA), states have submitted spending plans to the Center for Medicare and Medicaid Services (CMS) outlining how they intend to use these one-time funds to invest in home and community-based services (HCBS) that aim to keep individuals out of high cost institutional settings. These proposals reveal priorities across states for investing in home in community based behavioral health services.
State behavioral health systems have been experiencing multiple challenges since before the onset of the COVID-19 pandemic: the opioid crisis is ravaging communities, mental health crisis services are not sufficiently available, and behavioral health systems face serious staffing shortages. The pandemic has brought these crises into focus. Since 2019, more than half of states saw a more than 30% increase in overdose fatalities, emergency department visits for suspected suicide attempts by teenagers and young adults increased by 31%, and according to the Centers for Disease Control and Prevention (CDC), 40% of adults surveyed this spring reported struggling with their mental health or substance use. This accelerated demand for behavioral health services and the heightened risks of working in healthcare settings during the pandemic have left states facing staffing shortages, in some cases so severe that institutional settings are experiencing full on crises. Five of Virginia’s state mental health hospitals temporarily suspended admissions in July, Oregon’s state hospital saw a 45% increase in direct-care staff on COVID-related leave between February and March of this year, and New York Governor Hochul declared a statewide disaster emergency due to healthcare staffing shortages in September. As such, states and the federal government are preparing to make considerable financial investments in home and community-based services, to both relieve stressors on institutional settings as well as to provide comprehensive behavioral healthcare at an accessible delivery point to Medicaid members.
Developing and Enhancing Mobile Behavioral Health Crises Response
Through ARPA, states see an important opportunity to improve behavioral health systems, with a particular interest in enhancing crisis response systems. Several state HCBS spending plans propose to use funds to develop and expand the capacity of mobile crisis response, and some states plan to use these funds to bolster supports to specific, underserved populations. West Virginia and New York’s propose expanding existing mobile crisis capacity to better serve individuals with intellectual disabilities, while Michigan and Washington plan to build out crisis response for children. Other states propose using funds to add crisis stabilization units and to use ARPA funds to implement 988, a nationally-accessible hotline for people in suicide and other mental health crisis situations, established by the National Suicide Hotline Designation Act of 2020.
Updating Technology and Data Infrastructure
State HCBS spending plans underscore the need to improve technological capacity in HCBS systems. Several states propose extending facility-based data such as admissions, discharge, and transfer notifications to HCBS providers; others, including Alabama, Maine, New Jersey, and Texas plan to provide grants to providers and/or families for assistive technology and broadband access. Several states, including Colorado, plan to connect and share data across state agencies and/or among providers to better track and coordinate services for the HCBS population. Similarly, Georgia plans to develop a comprehensive case management platform for all HCBS populations that would include a dashboard for outcomes and reporting, streamlining data collection and usage. Georgia also builds in funding to train staff on new technology. New Jersey proposes using funds to develop a public facing registry, to allow members and families to access information on their waitlist status, available services, wait times.
Investing in the Behavioral Health Workforce
State HCBS spending plans reflect widespread and increasing shortages in the behavioral health workforce. States propose multi-faceted approaches: a handful of states seek to implement permanent rate increases for some sectors of the HCBS workforce, and North Carolina, Minnesota, Vermont, New York, and others plan to raise rates for mental health and substance use disorder (SUD) providers specifically. As a shorter-term strategy, other states are taking a specialty pay approach, building in one-time hiring and sign-on bonuses for behavioral health and other direct care workers. States are also planning to allocate funds for training staff to encourage specialization in behavioral health, or to develop specific skills particularly in-demand in the field. For example, Iowa plans to provide training and scholarships for Crisis Response and Behavioral Health Technician certification. Michigan plans to provide loan forgiveness and internships for students in behavioral health who commit to working in behavioral health shortage areas.
COVID-19 and its related risks in institutional settings have heightened the need for care in the community for people with significant behavioral health needs. State ARPA spending plans reflect the tremendous demand for behavioral health services across states, as well as the growing need to address workforce and build more technological capacity for a sector that has long lagged behind physical health systems. Nearly all state HCBS spending plans have been conditionally approved by CMS, final versions are likely to change in response to CMS comment and guidance.
Case Study of California’s ACEs Aware Initiative
Download the case study.
This case study highlights California’s ACEs Aware initiative and its key elements. The ACEs Aware initiative provides education, training and clinical protocols for the state’s Medicaid program (Medi-Cal) providers on screening for ACEs and covers the cost of screenings and related services under Medi-Cal. The goal of ACEs Aware is to identify and improve the health and well-being of Californians enrolled in Medi-Cal and who have experienced ACEs and toxic stress, providing a sustainable path to integrating identification and response to ACEs and toxic stress into the state’s Medicaid program.
This case study is the latest in a series from a partnership between NASHP, the National Governors Association, the Duke-Margolis Center for Health Policy, and a former state policy leader from Building Strong Brains Tennessee.
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. 
