The COVID-19 pandemic has exacerbated adverse childhood experiences (ACEs), and children could be facing a surge of poor physical and mental health outcomes without adequate investment and focus to reduce the effects of ACEs. This is especially important because Black, Latinx, and Native American children, who already disproportionately experience higher levels of ACEs, have also been impacted by the COVID-19 pandemic, in part due to longstanding inequities. A number of states are taking action. States like California and New Jersey have launched statewide initiatives to mitigate the long-term effect of traumatic events, and several state legislatures have introduced bills to identify and address ACEs in partnership with systems such as Medicaid and education.
In New Jersey, the Department of Children and Families’ (DCF) Office of Resilience released a statewide action plan in 2021 with a goal of helping children and families in New Jersey reach their full potential by focusing on prevention and reduction of childhood trauma and adversity in future generations. The DCF Office of Resilience was created in June 2020 during the pandemic, to host, coordinate, and facilitate statewide initiatives with the purpose of raising awareness of and creating opportunities to eradicate ACEs through grassroots and community-led efforts. Key components to implementing the new action plan include:
- Conducting a statewide literature and programmatic review to assess current efforts to address ACEs in the state,
- Meeting with non-governmental organizations to ensure actions are community-led and centered, and collaboration to highlight and promote an online community, and;
- Making data from the New Jersey Population Health Cohort study publicly available.
Both state strategies center community voices and highlight resilience as a protective factor against trauma, and both plans work in stages by first identifying the breadth and depth of trauma in children through screenings, and then using this information to create appropriate resilience-focused programs. Both California and New Jersey strive to proactively address the impact of ACEs, especially as children are exposed to compounding trauma living through a pandemic and help build a healthier future.
Proposed State Legislative Strategies
COVID-19 has exacerbated existing stressors and the trauma from the pandemic has created new ones, and states have been having active discussions about how best to serve the needs of children during the pandemic. Against this backdrop, legislators across states are considering new strategies to address ACEs. Most states’ legislative cycles are reaching their end and bills are at various point in the legislative cycle, but common themes in proposed legislation include:
- Publicly acknowledging the impact of trauma and importance of trauma-informed care. Illinois SR 212 declared May 25, 2021 “Trauma-Informed Awareness Day,” to, among other things, encourage all employees of the State to become informed regarding the generational impacts of ACEs, toxic stress, and systemic racism.
- Creating entities to identify areas of need and recommendations. A bill in Georgia seeks to create a House Study Committee on ACEs to improve the health of women and children. The bill was introduced after data from the U.S. Health Resources and Services Administration showed that in 2019, 23.6% of Georgia children lived in economic hardship, that economic insecurity is the most common ACE, and non-Hispanic Black children are nearly twice as likely to experience one or more ACEs. Similarly, a Maryland bill proposes establishing a “Workgroup on Screening Related to Adverse Childhood Experiences,” tasked with updating and developing screening tools, submitting the screening tools to the Department of Health, studying best practices, and making recommendations to the Governor and General Assembly.
- Increasing ACE and social determinant of health screening for children by Medicaid and education agency stakeholders. State legislatures are exploring:
- Requiring home health care professionals to use ACE questionnaires to assess patient health risk with reimbursement by Medicaid (NY).
- Requiring school district board of directors to conduct ACEs screenings for any child before taking disciplinary action and including the results in any reports explaining the disciplinary results (AR).
- Screening students for ACEs or traumatic events (CT, MD, PA). Pennsylvania’s bill requests a comprehensive analysis to identify an age-appropriate measuring tool that can be used by school districts to measure childhood trauma. Maryland’s bill requires the Secretary of Health to approve ACE training programs that providers can complete, to be reimbursed by Medicaid.
Unfortunately, nearly 40,000 children lost parents to COVID-19, and sustained investments will be critical to mitigate the effects of the trauma experienced during the pandemic. States are at different stages of promoting ACE awareness and addressing the effects of ACEs–identification and screenings are just the first steps toward improving long term health outcomes. Ongoing efforts to shine a light on this issue are moving ACEs towards mainstream consciousness at a critical juncture. As strategies in California, New Jersey, and other states demonstrate, awareness, community engagement, provider training, and critical partnerships are the first steps toward ensuring that children’s needs are considered and met. NASHP will continue to monitor state action including use of American Rescue Plan Act Funds to address ACEs. See related NASHP resources.
Since reaching an all-time low in 2016, the rate of uninsured children has climbed from 4.7 percent in 2016 to 5.7 percent in 2019. In response, several state legislatures are considering bills designed to improve children’s coverage options and promote child enrollment in Medicaid and the Children’s Health Insurance Program (CHIP).
Program and Enrollment Expansions
One of the most notable efforts to expand children’s coverage was included in New Jersey Gov. Phil Murphy’s fiscal year 2022 budget, which establishes the Cover All Kids initiative to provide coverage to all uninsured children. At an estimated cost of $20 million, it is forecasted to cover 88,000 children by expanding Medicaid eligibility thresholds and extending coverage to children currently ineligible due to immigration status.
The Cover All Kids program aligns with initiatives previously proposed by New Jersey advocates and legislators to ensure all children have coverage. The governor’s proposed budget also directs the Department of Human Services to eliminate premiums and the waiting list for children enrolled in CHIP and provides funds for an enhanced outreach campaign to increase Medicaid and CHIP child enrollment.
In Utah, lawmakers considered two children’s coverage bills during this session. In 2019, Utah had the third-highest increase in the rate of uninsured children and the highest rate of uninsured Latinx children in the country. In response to these troubling statistics, the Utah Legislature passed HB262, which creates the Children’s Health Care Coverage program. This program directs the Utah Department of Health, Department of Workforce Services, and the state Board of Education to develop a program to promote health insurance coverage for children when they enroll in school and when they apply for free and reduced lunch.
The Utah law also requires the state to:
- Conduct research on families who are eligible for Medicaid and CHIP to determine their awareness of coverage options;
- Analyze trends in disenrollment to identify barriers for coverage renewal; and
- Administer surveys to gather information about current enrollees’ experiences with the programs.
Findings from this research will be used to redesign the CHIP and children’s Medicaid enrollment websites and inform future outreach partnerships.
Another Utah bill, SB158, designed to address the state’s coverage crisis through the creation of a robust outreach program, focused on enrolling underserved populations, providing application assistance, and launching an advertising campaign to draw attention to coverage opportunities for children. In addition, the bill would have expanded public coverage to children whose family income fell below 200 percent of the federal poverty level (FPL). Despite senate approval, the bill did not pass.
Like Utah, Florida experienced a dramatic increase in childhood uninsured rates since 2016. The Center for Children and Families at Georgetown University’s Health Policy Institute 2020 report found that more than 55,000 Florida children had lost coverage between 2016 and 2019, representing the second-highest coverage drop in the nation during that period. Florida legislators are currently considering HB 201 and SB 1244, both of which would increase the eligibility threshold for their CHIP program from 200 percent of FPL incrementally by 20 percent each year beginning in the 2021-2022 fiscal year, until reaching 300 percent of FPL, which is expected in the 2026-2027 fiscal year.
In Maine, legislators are considering LD 372, a bill to expand access to CHIP. The bill includes provisions to:
- Expand income eligibility from 200 to 300 percent of FPL;
- Eliminate the waiting period for children whose families have lost employer-sponsored coverage;
- Extend coverage eligibility from age 19 to 20; and
- Eliminate premium payments for all enrollees.
Last week, the Georgia Legislature passed HB 163, which directs the Department of Community Health to seek federal approval to establish express-lane-eligibility (ELE) for children whose families apply for the Supplemental Nutrition Assistance Program (SNAP). By implementing the ELE option, children will automatically be enrolled or renewed in Medicaid or the state’s CHIP program, PeachCare for Kids, based on the current information provided in their SNAP application. State child health advocates estimate that this could increase child enrollment in Medicaid in the state by 70,000. Currently, five states use SNAP data to determine eligibility for Medicaid and/or CHIP.
CHIP Buy-in Programs:
Legislators in Iowa and West Virginia are considering bills to create CHIP buy-in programs, which allow families with incomes above their state’s CHIP eligibility thresholds to purchase coverage.
Iowa’s SF220 would allow families to purchase CHIP coverage for children and young adults up to age 26 whose household income exceeds the maximum income eligibility threshold of 302 percent of FPL. Iowa’s CHIP-buy in plan differs from traditional CHIP buy-in programs as it would allow families to purchase CHIP coverage for their children as an alternative to qualified health plans on the exchange or plans on the individual market — which unlike CHIP are not tailored to children’s needs.
The CHIP coverage would be sold through the marketplace, allowing families to compare their coverage options, and could be paid for with premium tax credits for eligible enrollees. If passed, the state would need federal approval to implement the plan.
West Virginia’s HB2278 would establish a buy-in program for children’s whose families earn more than 300 percent of FPL and could afford to pay the cost of CHIP coverage in full.
Despite states continuing to grapple with managing the COVID-19 pandemic, many are still seeking to improve coverage for children in Medicaid and CHIP. The National Academy for State Health Policy continues to track states’ efforts to increase enrollment in children’s coverage in Medicaid and CHIP.
More than 200 bills to lower drug prices have been filed across states during this session and nine states are proposing prescription drug affordability board (PDAB) legislation.
Nine states (AZ, CO, MN, NJ, NM, OR, RI, VA, and WI) are currently advancing PDAB bills in their legislatures. While a number of these bills are similar to Maryland’s approach that phases in upper payment limits by initially limiting them to public purchasers before potentially expanding them to include private purchasers, the majority of the currently proposed bills map more closely to NASHP’s original model legislation, which implements payment limits across all payers (public and private) in a state in a more expedited fashion.
The bills are generally similar in two approaches:
- They use similar price thresholds to identify a drug for investigation by their PDABs, and
- They apply the same factors when setting an upper payment limit for drugs found to be otherwise unaffordable – such as weighing the cost of administering the drug and delivering the drug to consumers.
Minnesota’s bill, however, includes unique language that empowers its PDAB to consider both the “the range of prices at which [a] drug is sold in the United States and the range at which pharmacies are reimbursed [for it] in Canada.” This language creates a bridge between the PDAB model and a newer approach in a recently released NASHP model law that creates payment rates for certain high-priced drugs based on Canadian pricing. This approach, reflected in NASHP’s Act to Reduce Prescription Drug Costs Using International Pricing, offers states a more streamlined approach than establishing a PDAB, which requires the complex task of determining the appropriate value of a drug in order to set an affordable payment rate. Five states (HI, ME, OK, ND, and RI) are currently considering international reference rate bills that use (or “reference”) Canadian prices to set more affordable rates.
As states consider PDABs and international reference rate approaches to achieve the goal of setting more affordable payment rates for drugs, there are several key factors to consider.
- While international reference rates look to Canada’s drug prices when establishing appropriate payment rates, PDABs keep the task of identifying affordable rates within a state.
- While PDABs may be conceptually preferable for this reason, the time and resources required to implement this approach may not make PDABs feasible for all states. For those states, using Canadian prices to set rates may be the most viable option.
Minnesota’s bill, however, points to a third option, a hybrid approach in which a PDAB would consider Canadian pricing as part of its process.
Explore this chart to compare the different state approaches and implementation timelines of the nine PDAB bills proposed as of March 9, 2021.
New Jersey, like many states, faces rising maternal mortality rates and racial disparities. A recent review of pregnancy-related deaths in the state from 2009 to 2013 found 46.2 percent of deaths occurred in Black women, compared to 26.9 percent in White women. With approximately 40 percent of New Jersey’s births covered by Medicaid, the governor’s office recently announced the following Medicaid initiatives to improve maternal health and reduce overall health care costs.
Medicaid Coverage of Doula Care: Legislation passed in 2019 enabled Medicaid coverage of doula services in the state. A doula is a trained professional who provides continuous physical, emotional, and informational support to the birthing parent throughout the perinatal period. Doula care has been shown to reduce cesarean rates, improve birth experiences, and improve birth outcomes. Once doulas receive the community-based doula training from an approved program, they are able to enroll as fee-for-service providers and with Medicaid managed care organizations.
New Jersey has designated two levels of doula care eligible for reimbursement, standard and enhanced care.
- Services for standard care include up to eight perinatal visits and attendance during labor and delivery with a reimbursement rate of $800.08.
- Enhanced care is for members age 19 or younger and services include 12 perinatal visits and attendance during labor and delivery with a reimbursement of $1,066.
- Additionally, for both levels of care there is an $100 incentive for postpartum, follow-up visits.
In order to receive the incentive payment, doulas must provide a postpartum service visit within six weeks of delivery and use the code 99199 HD U8 for billing. An obstetric clinician follow-up visit must occur within six weeks of delivery to receive the incentive payment but is not required for doulas to receive reimbursement for other services. Doulas serving Medicaid enrollees must be trained to provide culturally competent care that supports the diversity of the members and assist members with community-based services to improve health outcomes. Currently, Minnesota and Oregon cover doula services for all Medicaid recipients and New York has a pilot program running in two counties. Additionally, as directed by their state legislatures, Virginia and Washington State have submitted reports and studies on implementation of Medicaid reimbursement.
Increased Payments to Certified Nurse Midwives: In an effort to increase access to quality maternity services, New Jersey Medicaid has also increased the reimbursement rate of certified nurse midwives (CNMs) to be equivalent to 95 percent of the current rate for physicians who provide prenatal, labor and delivery, and postpartum services. A CNM is an advanced practice registered nurse (with a master’s degree in nursing) who specializes in the care of women throughout their life course, including pregnancy, childbirth, and the postpartum period. According to the most recent Pregnancy Risk Assessment Monitoring System (PRAMS) data, 33.1 percent of Black, non-Hispanic mothers in New Jersey reported receiving late or no prenatal care, compared to 14.6 percent of White, non-Hispanic mothers. The increase in reimbursement rates for CNMs is designed to build a larger network of midwives and increase access to quality pregnancy-related care for mothers and babies in New Jersey. As of 2013, approximately 34 states and Washington, DC, reimburse CNMs at 90 to 100 percent of the rate of earned by practicing physicians.
Medicaid Will Not Pay for Non-Medically Necessary, Early-Elective Deliveries (EED): In 2019, New Jersey passed a law that no provider will be approved for reimbursement by Medicaid for a non-medically indicated, early-elective delivery performed at a hospital on a pregnant woman earlier than the 39th week of gestation. Scheduled cesarean sections or medical inductions performed prior to 39 weeks carry risks for both mother and baby. Overall, New Jersey’s rate of surgical births (cesareans) is 30.3 percent. The benefits of non-surgical birth include shorter hospital stays, reduced infection rates, lower blood clot risk, and fewer infants born with difficulty breathing. Currently, 20 states have reduced or eliminated payment for procedures (EEDs, elective inductions, and non-medically necessary cesarean sections) that do not follow clinical guidelines. The new Medicaid policy in New Jersey supports education campaigns and hospital initiatives that are already in place to lower non-medically necessary EEDs. The new policy will not affect mothers who have medical indications for early delivery.
Providers Required to Complete the Perinatal Risk Assessment (PRA) Forms: In 2019, the state passed a law requiring Medicaid providers to complete PRAs during the first prenatal visit for all Medicaid enrollees. The tool is used to identify demographic, medical, and psychosocial factors that can help determine case management plans for pregnancies. The PRA form has been updated to included assessment of alcohol and drug use and COVID-19-related challenges. The state will use the data collected from the PRAs to analyze and identify risk factors among pregnant Medicaid enrollees in the state.
State Medicaid programs have the opportunity to implement policy changes, similar to New Jersey’s, that support improving maternal and infant health outcomes. Given current budget challenges in states, funding can be challenging, but these policy changes can result in cost savings by lowering cesarean rates, decreasing length of stays in hospitals, and improving overall birth outcomes. The National Academy for State Health Policy (NASHP) will continue to track state maternal and child health policies.
A 2016 New Jersey law gave the state flexibility to share bid information submitted by all pharmacy benefit managers (PBMs) in order to incentivize the PBMs to submit lower offers in additional rounds of bidding – a process known as a reverse auction. While reverse auctions have been used historically to procure goods, New Jersey’s first-in-the-nation PBM model represents a new way states can procure services and save millions on prescription drug spending.
Confronted with a pandemic that impacts the health of women and children – ranging from pregnancy and delivery to access to substance abuse treatment – a consortium of New Jersey state and health care experts launched a Project ECHO (Extension for Community Healthcare Outcomes) initiative to share COVID-19 expertise between specialists and primary care to meet the needs of women during the crisis.