What can States do during Public Health Crises? Lessons Learned from Environmental Threats in Michigan, Rhode Island, and West Virginia

twitterWhen it comes to prevention, identification, and mitigation of public health crises states are at the forefront. These crises require a multi-sector state agency approach as often they disproportionally impact disadvantaged communities and are linked with challenging social determinants of health.

The conversation regarding preparation and mitigation of these disasters has received increased national attention in the wake of the Flint water crisis. NASHP recently brought together three state leaders to share their perspectives on the role of states, policy implications, interagency collaboration, and lessons learned. Strategies range from Medicaid financing for services, legislative and regulatory requirements to promote prevention, and multi-sectorial partnerships.

Michigan – Medicaid as a Supportive Infrastructure
Michigan has been in the midst of crisis management since October 2015 when corrosive elements in city pipes resulted in lead leaching from the pipes into the water, rendering it undrinkable. More than a year later, the water is still unsafe without a filter. The expanse of this crisis created the need for a long-term stable support mechanism for the community. State officials turned to Medicaid due to its robust infrastructure to support long-term health needs. Michigan moved rapidly with support and fast-track approval from the Centers for Medicare and Medicaid Services to create a Medicaid 1115 waiver. This waiver expands coverage to 400 percent of the federal poverty line (FPL) for children and adults up to 21 years of age, and all pregnant women.

Eligibility for the waiver is based on exposure to lead and is determined by matching eligibility files to addresses served by the Flint water system (residence, employer, childcare provider, school) between April 2014 and a future undetermined date when the water is deemed safe. Due to complexities of the crisis and the long-term effects of lead poisoning, the waiver has been designed as a support mechanism across time and geographic areas. The waiver provides those eligible with targeted case management and links individuals to clinical services, educational support, and food assistance to remediate the impact of lead exposure. The community health system in Flint has been tapped to work with local citizens and organizations to increase health coverage. Since the waiver was approved, initial coverage rates have been slow but primary care visits for children and pregnant women have increased. Overall, Michigan has illustrated how states can leverage the unique size and scope of the Medicaid program to support beneficiaries over time across city and county jurisdictions.

Rhode Island – Using a Multi-Agency Policy Approach for Prevention
In Rhode Island, lead poisoning rates have substantially decreased over the past 15 years, in part due to key detection and prevention policies. Rhode Island’s universal lead screening policy requires all children to have lead screening between nine and 15 months and again at least 12 months later. Of those children screened, 49 percent are covered by Medicaid, and 70 percent of those with elevated blood lead levels are covered by Medicaid. The statewide Medicaid case management policy refers children with lead levels of concern to one of four lead centers. These centers provide both medical and nonmedical case management, which is reimbursable via Medicaid (but not currently covered by private insurance). Comprehensive environmental lead inspections (CELIs) are offered to families of children with higher blood levels and include an analysis of paint, dust, water, and soil in the home. Results of these tests have shown lead hazards are often from the home rather than the water. Rhode Island’s Medicaid 1115 waiver provides payment for window replacements to assist in mitigating hazards. To review the various regulations and identify areas for improvement and enforcement, Rhode Island has created a commission that is mandated to bring together Department of Housing, Department of Health, Medicaid, Environmental Management Agency, and the Attorney General’s office. To prevent and mitigate potential disasters, Rhode Island has emphasized its multi-actor approach that takes into account both social and environmental determinants and their effect on the public’s health.

West Virginia – Creating a Foundation to be Better Prepared for the Future
On the afternoon of January 9, 2014 a 1,000 gallon chemical spill in the Elk River left nine counties in West Virginia with no potable water. Local communities did not receive information until six hours after the spill. This initial delay in communication, combined with a lack of information from the company responsible for the spill, created trust issues between government and the local community.

The Centers for Disease Control and Prevention (CDC), the National Guard, and West Virginia environmental and public health state employees worked collaboratively on water screenings and a community assessment to provide information regarding water safety. However, the company continued to release information indicating an expanded scope and scale of the spill, thus exacerbating existing mistrust that continues today. With over 300,000 individuals affected, legislation was enacted within three months to further protect the state water sources. The law requires regulation and inventory of above- ground storage tanks, a source water protection program, and a public water supply study commission. Today, 125 facilities across the state have created source water protection plans. In addition to the new regulations and water protection program, West Virginia is modeling the impact of potential future crises, looking at how to bring technical experts together faster, and creating a foundation to be better prepared.

These states provide a snapshot of approaches that, as a part of a comprehensive state strategy, can make an impact on the prevention, identification and mitigation of environmental threats. They demonstrate the ability of states to use available tools and to be nimble in creating policies that respond to urgent needs with Michigan and West Virginia enacting policies within three months of their crises. All three states emphasized the importance of multi-sectoral, cross-agency partnerships that include Medicaid and public health.

These experiences raise key questions for states to consider: (1) What preparations have been made both as individual agencies and collectively across agencies to avert crises or manage them once they occur? (2) What are the social, political, and economic costs of a lack of preparation for these situations? (3) How can states support low-income low-resource neighborhoods that face greater environmental health threats to prevent disasters? (4) When crises impact communities that have traditionally been marginalized, how do state officials communicate with residents who may be distrustful of interventions, particularly as new information is emerging and the science is constantly evolving? Lessons will continue to emerge as states wrestle with these situations and use innovative approaches to prepare for and mitigate environmental threats.