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Ensuring Sustainability and Reach of COVID-19 Vaccine Distribution
As part of a comprehensive effort to support state leaders as they navigate the COVID-19 response, the Duke-Margolis Center for Health Policy and the National Academy for State Health Policy (NASHP) convened a meeting in July 2021 with a geographically diverse set of state officials and national experts to share best practices and innovative approaches to increase COVID-19 vaccinations.
Though the landscape continues to evolve rapidly, the participants discussed several themes that remain relevant given the current state of the pandemic. Participating state officials discussed strategies to reach unvaccinated individuals and policy and operational shifts to living with COVID-19 as a constant rather than a crisis.
This issue brief includes a summary of the meeting discussion as well as additional details on specific state approaches, including:
- Identifying reasons for hesitancy and identifying effective, culturally responsive messaging to reach all populations
- Enhancing targeted partnership and outreach and including trusted messengers
- Reducing barriers to vaccine access in primary care settings
- Engaging communities and providing easy access
- Using financial strategies to incentivize vaccine uptake
- Navigating political and legal issues
- Improving the use of data to increase equitable access to vaccines
Washington Demonstrates Cost Savings and Improved Outcomes from Supporting Family Caregivers
Washington has been at the forefront of providing supports to family caregivers, in large part, because state policymakers have been able to demonstrate cost savings and improved quality of life. Washington’s Medicaid Transformation Project proactively supports caregivers of individuals likely to spend down to Medicaid long term services and supports (LTSS). It was designed after Washington’s Family Caregiver Support Program, (FCSP) which assesses caregivers and provides training, respite, and other resources. Robust data collected from these programs demonstrate that Washington’s investments in family caregivers have ultimately contained costs while improving the wellbeing of caregivers and individuals receiving care.
Proven Return on Investment
Washington’s comprehensive Medicaid 1115 waiver program, the Medicaid Transformation Project, has shown a return on investment since its inception in 2017. This waiver has two caregiver support programs: Medicaid Alternative Care (MAC), which serves caregivers of Medicaid-eligible individuals not using Medicaid LTSS, and Tailored Services for Older Adults (TSOA), which supports individuals and caregivers of individuals who are not yet eligible for Medicaid or are choosing to not participate in Medicaid, but likely to eventually need Medicaid LTSS. TSOA and MAC both offer similar benefits for caregivers, including:
- Caregiver assistance with household tasks, respite, home-delivered meals, and minor home repairs
- Training and education
- Specialized medical equipment and supplies
- Health maintenance and therapy supports, such as adult day centers and counseling
The dollar value of the benefits depends on the caregiver’s assessment. Caregivers are eligible for benefits if they receive a screening with TCARE, an evidence-based tool for assessing a caregiver’s own needs. Caregivers can receive up to $4,362 over a six-month period depending on their assessed level of need and care plan. Eligibility is determined primarily by age, income, and assessment, with more flexibility with income and asset limits than traditional Medicaid. Perhaps due to these flexibilities, more individuals and caregiver/recipient pairs have enrolled in TSOA than MAC. Enrollment in the program has been lower than anticipated, in part due to challenges reaching people who do not self-identify as caregivers.
| Eligibility for Medicaid Transformation Project LTSS Initiatives | |
| Medicaid Alternative Care (MAC) | Tailored Supports for Older Adults (TSOA) |
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Washington analysts determine cost effectiveness with a synthetic estimate projection, a method of statistical analysis that compares actual expenditures with projected expenditures if no program had been implemented. Though the waiver is still in progress, data from the first few years show that the program is succeeding in delaying Medicaid LTSS and preventing hospitalizations. Furthermore, survey results find high levels of satisfaction among caregivers and recipients. Washington’s evaluation is largely based on data from TCARE family caregiver assessments combined with data on emergency department visits, inpatient admissions, 30-day readmission rate, nursing home admission rate, and mortality rate.
Prior to the initiation of the Medicaid Transformation Project, Washington used data to demonstrate the cost-effectiveness of expanding its Family Caregiver Support Program (FCSP) in 2012. Under Washington’s FCSP, interested caregivers receive a TCARE screening. Subsequently, eligible caregivers receive support in finding local resources, training on caregiving topics, help with securing respite, and advice and support on specific challenges. This assessment strategy produces a range of data on caregivers and recipients of care and allows the state to establish a baseline from which to study the impact of the program. In an analysis of the FCSP expansion, Washington found that care recipients whose caregivers were screened following FCSP expansion were 20 percent less likely to enroll in Medicaid LTSS in the year post-screening, controlling for other factors. These results identified a return on investment using baseline and implementation data, demonstrating the value of the state’s investment in caregivers and serving as a precursor to the Medicaid Transformation Project waiver.
Multi-Faceted Approach to Support Caregivers and Reduce Medicaid Costs
Washington’s efforts on caregiver supports are multi-faceted to delay the need for Medicaid services. Both Washington’s FCSP expansion and its Medicaid waiver place an emphasis on identifying caregivers in need of support before more formal LTSS are needed and connecting them with resources. These initiatives align with other efforts Washington has taken to support caregivers and older residents, including the state’s Paid Family Leave program and its first-in-the-nation public long-term care insurance program. The combination of these supports, emboldened by robust data demonstrating their effectiveness, forms a cohesive caregiver support strategy that allows Washington to provide LTSS care while spending less per resident on Medicaid LTSS than the national average.
Acknowledgement: Thank you to Susan Engels, Office Chief, Home and Community Services, Washington State Department of Social and Health Services, for presenting much of this information to NASHP’s State Medicaid Policy Institute on Family Caregiving on June 16, 2021. This blog is part of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center and is supported by The John A. Hartford Foundation.
RAISE Family Caregiving Advisory Council Releases Report to Congress: September 2021 Meeting Summary
On Tuesday, September 21, the RAISE Family Caregiving Advisory Council met to discuss the release of the RAISE Initial Report to Congress and recognize the outstanding work of all those who helped make the report a reality.
Call to Order
Acting Administrator and Assistant Secretary for Aging of the Administration for Community Living (ACL) Alison Barkoff began the meeting by commending the council for their work in completing the report to Congress, especially under the challenging circumstances of the COVID-19 pandemic. This report is the first major step of the RAISE Act, and the recommendations serve as the foundation for the next step, the National Caregiver Strategy. Barkoff expressed her eagerness to move expeditiously on the National Caregiver Strategy and seize this opportunity to support America’s 53 million caregivers.
Overview of Report
Council co-chairs Nancy Murray, MS, Casey Shillam, Ph.D., and Alan Stevens, Ph.D. shared their appreciation for the report as the culmination of years of advocacy and two years of intense work with a wide range of stakeholders. While caregiver stories are intensely personal and unique, the report captures common themes across all caregivers. They also expressed their gratitude for the help that NASHP, ACL, and The John A. Hartford Foundation provided.
Following the co-chairs’ presentations, Barkoff shared a video featuring numerous caregivers speaking about their experiences with caregiving. Following the video, Barkoff spoke with two family caregivers featured in the video, Sarah and Debbi. Sarah discussed how important it is for caregivers to be engaged as partners in an individual’s care. Debbi shared the challenges and sacrifices she has made to serve as a caregiver to her son, but also the powerful bonds for her entire family that have formed through caregiving. She described caregiving as giving quality of life to others and said that it has enhanced her life in ways she could not have imagined.
Looking Ahead to the National Strategy Development
Jessica Schubel, Director of Affordable Care Act and Health Care for the Domestic Policy Council at the Executive Office of the President, shared the Biden administration’s priorities on family caregiving. She described how states can use the American Rescue Plan to expand home and community-based services (HCBS) by using funding to support telehealth, reduce waitlists, and pay for transition costs. Other possibilities to support family caregivers include paying for supplies and equipment, PPE, and in-home vaccination.
Two speakers from the National Alliance for Caregiving (NAC) followed Schubel. First, Mike Wittke shared how caregiving is a dynamic experience. As a result, it is important that the strategy receives ongoing attention to ensure it remains effective. Then, C. Grace Whiting of NAC shared the five pillars of the national effort to implement the RAISE Act:
- Awareness and outreach- not all caregivers identify as such and some resist the label. It is the responsibility of systems to reach out to individuals, not vice versa.
- Recognizing caregivers as partners- the CARE Act is a good start, but there are other opportunities to engage caregivers, such as those in the 21st Century Cures Act 2.0.
- Income security- caregivers would benefit from paid family and medical leave and wage replacement programs. Additionally, the Credit for Caring Act and universal family care would assist caregivers and recognize the value of their work.
- Family centered support- Important work is being conducted to engage the caregivers who are often forgotten, especially young caregivers. State actions like Maryland’s Caregiver Services Corps have helped during COVID.
- Research and data gathering- Actions like expanding the caregiver module of the Behavioral Risk Factor Surveillance System (BRFSS) and implementing the strategic plan created by the National Institute of Nursing Research would help with gathering robust, consistent data.
Closing Remarks
Alison Barkoff concluded the meeting by once again expressing her excitement for the release of the report and for this opportunity to change the landscape for caregivers. She ended the meeting by expressing that the strategy will recognize the hard work of caregivers to let others live with dignity and independence, with the hope that the report will make caregiving sustainable.
Virginia Advances Maternal Health Equity Policy
Nationwide, the maternal mortality rate for Black people who are pregnant is three times the rate for White non-Latinx people. In response to calls for Virginia to mitigate disparate maternity outcomes, Governor Ralph Northam announced in June 2019 that his administration would prioritize eliminating the racial disparity in the state’s maternal mortality rate by 2025. Virginia has since taken definitive actions to reach that goal, including hosting statewide listening sessions with communities of color and developing a comprehensive Maternal Health Strategic Plan. The plan outlines recommendations and related budget investments to support maternal health equity and address structural racism.
Virginia’s efforts mirror trends at the federal level to address systemic maternal health racial disparities. In April 2021, the Biden Administration outlined early federal actions to address the U.S. maternal mortality crisis, its disproportionate impact on Black and Indigenous pregnant people, and ‘address the systemic racism that has allowed these inequities to exist.’ Actions in the first 100 days of the Biden Administration include funding for the implementation of implicit bias training for healthcare providers, the creation of state pregnancy medical home programs, and the enhancement of Maternal Mortality Review Committees.
The Black Maternal Health Momnibus Act of 2021, recently introduced in the House, builds on existing federal legislation to comprehensively address social and health systems that impact the care of pregnant people throughout the country. Other recent federal legislation such as the Maternal Health Quality Improvement Act of 2020, passed by the House in September 2020, includes similar goals to address maternal mortality such as supporting provider implicit bias and health equity training, funding for state perinatal quality initiatives, and expanded provider access to people living in rural communities.
Virginia reflects a growing call by states and federal agencies including the Centers for Disease Control and Prevention, to focus on racism as a public health emergency, creating opportunities for state policy makers to highlight a root cause of health inequities faced by people of color. This focus also led the state to view maternity care through a holistic lens, including policy interventions that address social and health systems that serve people who are pregnant and their families. In particular, Virginia’s doula Medicaid benefit mirrors a growing national trend to utilize this service as a key component of a comprehensive strategy to improve maternity care outcomes for people of color.
Virginia’s policy targets six areas with actionable recommendations specific to eliminating racial inequity: insurance coverage, the healthcare environment, criminal justice and child welfare response, community-based services, contraception, and data collection. Governor Northam’s Administration outlined key lessons learned from community listening sessions during the plan’s development, often centering the voices of people of color with lived experience. This process reflects the state’s desire to engage with traditionally marginalized communities, which can be an important step in addressing structural racism in health care. State policy recommendations include:
- Investing in a doula Medicaid benefit,
- Requiring provider cultural humility trainings,
- Ensuring health systems are connected to community programs,
- Mandating maternal mortality specific education for primary care providers,
- Investing in home community health workers and home visiting services, and
- Identifying strategies to improve mandated reporting of race/demographic data related to maternal health outcomes, among others.
Virginia also demonstrates a commitment to addressing racism through an emphasis on both a diverse maternity care workforce and integrated cultural humility training among health care professionals serving people who are pregnant. Workforce development activities include behavioral health training, certification, and licensure practices that create opportunities for people of color. Culturally appropriate educational campaigns to destigmatize maternal health are another prominent component of the plan. The state also explicitly identifies opportunities to encourage the adoption of evidence-based clinical practices to support positive birth outcomes including expanding the state’s Maternal Health Learning Collaborative.
The state’s plan is accompanied by new investments in maternal health care. Virginia’s 2021-2022 budget includes funds to advance maternal health initiatives, many of which were designed based on community feedback. Budget initiatives support increased access to substance use disorder treatment for pregnant people, greater access to contraceptive care, and new medical coverage options for pregnant individuals who were previously ineligible because of their immigration status. It also includes extended postpartum coverage for Family Access to Medical Insurance Security (FAMIS) MOMS beneficiaries, a program that provides insurance for people who are pregnant and meet a certain income threshold. Extended postpartum coverage is a policy trend states are increasingly advancing to reduce maternal mortality rates.
As states advance maternal health equity and work to eliminate the current maternal mortality crisis, they can look for opportunities to address systemic racism in part by ensuring community voices are at the center of policy development. Virginia’s Maternal Health Strategic Plan presents an opportunity for the state to reimagine maternity care while holistically addressing intersecting social and health systems. It also demonstrates the power of cross-sector partnerships to align goals and improve the quality of care for pregnant people of color and their families.
NASHP continues to work with Virginia and seven other states (Georgia, Idaho, Illinois, Iowa, Louisiana, Pennsylvania, and South Dakota) on building capacity and implementing policy changes to address racial inequities in maternal mortality through the Maternal and Child Health Policy Innovation Project (MCH PIP).
Final 2022 Insurance Rule Rescinds Trump Administration Policies, Establishes Special Enrollment Period for Low-Income Households
On September 17, the Departments of Health and Human Services (HHS) and the Treasury issued a final rule governing marketplaces and qualified health plans sold through the marketplaces in 2022. The final rule largely codifies changes proposed in June including several changes to rescind policies made under the prior administration including:
- Repealing prior guidance on 1332 state innovation waivers that significantly broadened the interpretation of the legislative guardrails governing affordability and comprehensiveness standards of waiver proposals;
- Reinstating requirements for Navigators to engage in post-enrollment activities including assistance with eligibility appeals, tax credit reconciliation, and support for consumers with how to use coverage;
- Repealing a currently unutilized option for states to use Direct Enrollment entities to operate their marketplace; and
- Repealing a requirement for issuers to send separate bills and collect separate payments to cover non-Hyde abortion services.
Extending open enrollment and establishing a low-income special enrollment period
The new rule finalized two significant changes related to enrollment periods. The rule extends the open enrollment period (OEP) for states that use the federally-facilitated marketplace (FFM) from December 15 to January 15. States that run their own marketplace (SBMs), may opt to adopt the new OEP or maintain the December 15 deadline.
The rule also creates a new special enrollment period (SEP) specifically for households with income under 150% of the federal poverty level (FPL, $39,750 for a family of four, $19,320 for an individual). The SEP is designed to increase opportunities for low-income consumers to access coverage, especially in circumstances where they may not have been aware that they qualified for financial assistance. The rule notes the important role this SEP may serve in helping consumers maintain coverage, including the millions who are expected to lose Medicaid coverage when disenrollments are reinstated for individuals who may have become ineligible for the program during the public health emergency (PHE). (For more on the end of the PHE, see New Guidance for Unwinding Federal COVID-19 Public Health Emergency Provides State Flexibility and Medicaid Enrollee Protection).
The SEP would apply only when sufficient federal tax credits are available so that benchmark coverage can be purchased at $0 premium cost by these households. Currently, this SEP would only apply during the 2021 and 2022 coverage years during which an expansion of tax credits enabled under the American Rescue Plan Act (ARPA) provided an increase in tax credits so that households with income up to 150% FPL pay $0 for a benchmark plan. Congress is currently debating whether and how long to extend the ARPA tax credits as part of its ongoing negotiations over budget reconciliation. Without APRA’s tax credit enhancements, these households pay up to 4.14% of their income to cover benchmark premium costs.
The rule sets a series of parameters for individuals who enroll using this SEP. First, if they are a new marketplace enrollee, they may enroll in a plan at any metal level. However, current enrollees—including enrollees adding a dependent to their coverage—are limited to continuing enrollment in their current plan or may switch to a silver-level plan (which includes the $0 benchmark coverage). Second, the rule allows that enrollees may attest to income when applying for coverage under this SEP. SBMs may adopt the new SEP at their discretion and have flexibility over whether to require stricter parameters for income verification.
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. 
