Individuals experiencing homelessness often face more barriers to obtaining a COVID-19 vaccination than others. As more vaccines become available and supplies increase, new and emerging best practices for vaccinating individuals in homeless shelters may help states more efficiently vaccinate other hard-to-reach or medically vulnerable populations, such as those living in rural areas or congregate settings.
The Centers for Disease Control and Prevention (CDC) classifies individuals experiencing homelessness as a high-risk population. Homeless shelters are congregate settings, which can facilitate the rapid spread of COVID-19 infection, and many individuals who are homeless also suffer from other medical conditions that put them at high risk of COVID-19-related complications. While some states group all individuals residing in congregate settings into one vaccination priority category, others specifically identify individuals in homeless shelters as a priority population. As a result, these individuals’ vaccination eligibility differs between states.
According to a recent analysis by the National Academy for State Health Policy (NASHP), 34 states explicitly include residents of homeless shelters as a priority population. A few states, including Wyoming and Washington, DC, explicitly prioritize “individuals experiencing homelessness.” Washington State lists “people experiencing homelessness that access services or live in congregate settings (e.g., shelters, temporary housing)” in its latest vaccine prioritization plan.
Every state has changed its eligibility criteria and prioritization guidelines as the CDC and the Department of Health and Human Services (HHS) have issued new recommendations based on the constantly changing vaccine rollout picture. Some states have identified these individuals in their plans and moved this population up in priority, while others have instead reprioritized other populations. For example, Wyoming recently moved individuals experiencing homelessness up in their prioritization. Arizona elevated individuals with high-risk medical conditions living in shelters as well all adults in congregate settings. Wisconsin added individuals in homeless shelters and in transitional housing to a priority phase of the state plan after previously not prioritizing this population. As of March 1, 2021, 15 states were vaccinating individuals experiencing homelessness.
In addition to the general vaccine distribution challenges states are facing – such as limited vaccine supplies, tracking data on doses administered, personnel shortages, and vaccine hesitancy – vaccinating individuals experiencing homelessness has its own difficulties:
- Conflicting priorities: On top of concerns about vaccine safety and mistrust of the health care system, many individuals experiencing homelessness are hesitant to receive the vaccine because they see other challenges – such as housing status, food insecurity, and financial instability – as more immediate concerns.
- Transportation barriers: Many individuals experiencing homelessness face transportation barriers that prevent them from traveling to mass vaccination clinics.
- Tracking second doses: For those who receive the Moderna or Pfizer vaccines, the state must figure out how to track where individuals are to ensure they receive their second dose and are fully immunized. It is particularly challenging for states to track second doses for individuals who are only in a shelter temporarily, or primarily live on the street.
- Limited technology: Many people living on the street or in shelters do not have internet access, and therefore cannot sign up for vaccine appointments through state websites.
- Connection to health care providers: Individuals experiencing homelessness are less likely to be connected to health care providers or health care systems, making it more difficult to get an appointment or find out when they are eligible.
- Vaccine Storage: In order to reach individuals living on the street, providers need to be able to transport doses to encampments and other areas where individuals frequently live. However, the vaccines’ refrigerated storage requirements make bringing doses directly to individuals on the street difficult.
States are working diligently to determine strategies and best practices for vaccinating individuals experiencing homelessness. As supply increases and becomes less of a barrier to vaccine administration, it is critical to address access-related barriers that may prevent some individuals from receiving the vaccine and exacerbate existing health disparities.
As with most decisions related to vaccine distribution, eligibility criteria for priority populations has been left to states. Of the limited states already vaccinating individuals experiencing homelessness, many have turned to private organizations to aid in vaccinating individuals experiencing homelessness. In these cases, the state distributes doses to nonprofit organizations that work to address homelessness or provide health care to the homeless, and these organizations take the lead in organizing clinics and administering doses.
Since early February 2021, the Washington, DC Department of Human Services has partnered with Unity Health Care, the District’s largest network of federally qualified heath centers, to hold vaccination clinics at homeless shelters. Unity Health Care is also trying to vaccinate individuals living on the street when possible through case managers and outreach teams. Washington, DC is eliminating certain barriers to vaccination for individuals experiencing homelessness, including waiving the requirement to provide an ID at appointments, giving individuals waterproof wallets in which to keep their vaccination cards, and providing free transportation to clinics located at some homeless shelters.
In Connecticut, the state and local health departments are coordinating vaccination efforts in congregate facilities – including homeless shelters – affiliated with the state, and partnering with private nonprofits to actually administer the doses. Some hospitals and cities in Connecticut are also using mobile vaccination clinics to reach individuals in congregate settings.
In Massachusetts, the nonprofit Boston Health Care for the Homeless Program (BHCHP) is playing a crucial role in vaccinating individuals experiencing homelessness in the Boston area. BHCHP is leveraging the City of Boston’s Homeless Management Information System (HMIS) – which connects to their electronic health records system Epic – in conjunction with the state’s Immunization Information System (IIS) to track first doses administered and to send out second dose text reminders. Shelter can access these reminders and provide outreach to patients to make sure they get their second doses. BHCHP is also using their grant funding and their own funding to incentivize vaccinations among the populations they serve, including providing gift cards, clothing, and snacks and combatting vaccine hesitancy by training individuals experiencing homelessness to provide peer counseling. To date, the nonprofit reports it has been successful at ensuring individuals return for their second doses. BHCHP also announced plans to start vaccinating individuals living on the street. They hope to use a van to store doses while they drive to areas where individuals on the street often live.
As states try to simultaneously provide information about vaccination clinic locations, recruit and train personnel to administer vaccines, monitor individuals after vaccination, and plan mass clinics, nonprofits are a valuable resource for reaching specific populations. Many private organizations, especially those already working to address homelessness and housing insecurity, have existing relationships with individuals experiencing homelessness and are already trusted service providers. They have been providing outreach to these communities throughout the pandemic and are poised to take on some of the work of vaccinating individuals experiencing homelessness.
Because demand for the vaccine still exceeds supply, states are challenged to prioritize their populations. States have to make tough decisions that promote health equity, decrease infection rates, promote vaccine efficiency, and prevent deaths. States that have not yet started vaccinating individuals experiencing homelessness can learn from others that are already vaccinating this population so that they can more effectively reach those living in shelters and on the street.
As states – and their partnering nonprofits – pilot strategies like mobile vaccine clinics and offer incentive payments and peer counseling in order to reach individuals experiencing homelessness and encourage vaccinations, these and similar initiatives can inform efforts to vaccinate other hard-to-reach populations.
Acknowledgements: This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
Nursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.
A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.
Maximizing the Flexibility of Home- and Community-Based Waiver Services
Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.
Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.
Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals
To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:
- Leverage regional and local leadership to coordinate a unified response; and
- Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.
To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.
Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:
- A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
- Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
- Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.
Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.
While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:
- Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
- Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
- Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.
State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.
As development of a COVID-19 vaccine continues, states are racing to develop vaccine distribution plans and are eager to ensure that the administrative challenges of testing and personal protective equipment distribution are not repeated. They must orchestrate vaccine storage and administration, data tracking, and capacity issues while questions about who will ultimately pay for the massive vaccine deployment, how it will be equitably distributed, and effective vaccine messaging require a uniform federal response for best results.
State leaders also raised concerns about a variety of challenges they face in distributing the COVID-19 vaccine, such as a lack of clarity on federal funding for vaccine administration, refrigeration and storage, and availability of state funding.
According to the CDC playbook, the federal government will procure and distribute the vaccine and any associated supplies (including needles, syringes, and limited masks and face shields) at no cost to providers. Typically, insurance reimbursement to providers includes the cost of the vaccine itself and some of the associated administrative cost. The National Academies of Sciences, Engineering, and Medicine (NASEM) recommended in its framework for equitable vaccine allocation that vaccines be made available at no cost and that administration of the vaccine be adequately reimbursed. However, it is unclear how administrative expenses will be covered and by whom.
Other complications to state planning efforts include:
- What and how many vaccines will be rolled out, and over what time periods; and
- What refrigeration temperature requirements will be.
For example, given the storage and temperature requirements of one COVID-19 vaccine currently in clinical trial, states are concerned about additional costs of storing, freezing, delivering, and administering vaccines. CDC, meanwhile, has instructed states not to invest in ulta-cold freezers yet.
Vaccine administration can also be prohibitively expensive for facilities. Because there are still so many unknowns about which vaccines will be available and how they will be transported, details about who will ultimately finance these costs are still being finalized. State officials expressed concern that as they face budget crises and limited federal information and regulations, they are being set up to fail.
Who will be the first to be vaccinated?
The CDC recommends that states establish COVID-19 vaccination program implementation committees with representatives from every sector and from communities. The NASEM framework highlights the need for equal regard, maximization of benefits, evidence-based actions, and transparency in decision-making. NASEM and the Advisory Committee on Immunization Practices (ACIP) have been discussing how to prioritize the distribution of the COVID-19 vaccine to critical populations, but delayed making a final decision until a vaccine has been approved by the US Food and Drug Administration for clinical use.
Source: CDC COVID-19 vaccine implementation presentation, July 29, 2020.
The CDC playbook highlights a phased approach to distributing the vaccine and delineates three phases of distribution. However, during Phase 1, which has a limited supply of COVID-19 vaccine doses available, states are encouraged, but not required, to focus their initial efforts on reaching critical populations, including:
- Health care personnel who are likely to be exposed while treating people with COVID-19;
- Those at increased risk for severe illness, including those with underlying medical conditions and people age 65 years and older; and
- Other essential workers.
These phases align closely but differ slightly from NASEM’s equitable distribution framework for Phase 1.
Most state officials noted they intend to follow this guidance for prioritizing an equitable vaccine distribution. But, some states also noted concerns regarding using their immunization systems to identify and distribute the vaccine to these populations, especially to those who live in large, sparse, rural, and frontier areas with smaller public health administrative capacity. Others raised concerns about whether individual providers will be able and willing to administer the vaccine, and if they can do so in a way that follows the equitable allocation framework. Their concerns are tied to cost and reimbursement levels, as well as physical capacity to store and refrigerate the vaccines. Additional federal guidance and funds could alleviate these issues.
Who will pay for the vaccine and associated costs?
The NASEM framework recommends that the COVID-19 vaccine be provided and administered with no out-of-pocket costs. Paul Mango, HHS deputy chief of staff for policy, said the agency’s goal is for the COVID-19 vaccine to be free for all Americans. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, similarly noted, “… The vaccine itself has already been bought by the federal government… A person who gets a vaccine will not pay for the vaccine.” However, Fauci did note that patients could be charged for costs related to the vaccine’s administration. Confusion remains about how these decisions will be made and it remains unclear how administrative expenses will be covered and by whom. For example, in the VFC Program, a provider who administers a qualified pediatric vaccine to an eligible child may not impose a charge for the cost of the vaccine, but can charge a fee for its administration as long as the fee does not exceed the costs of the administration.
ACIP has not yet issued a recommendation on state coverage of a COVID-19 vaccine, but Section 2713 of the Public Health Service Act requires mandatory coverage of all ACIP- recommended vaccines for state Medicaid expansion programs and most commercial health plans (state-based exchanges). ACIP-recommended vaccines are considered preventive and therefore are not subject to cost-sharing by patients. In March, Congress added a COVID-19 vaccine to the list of vaccines commercial health plans are required to cover. Usually insurers have up to a year after a vaccine is recommended by ACIP to implement coverage, but the CARES Act drastically speeds up this timeline by requiring plans to cover a COVID-19 vaccine within 15 days of its approval. The Coronavirus Preparedness and Response Supplemental Act specified that a vaccine should be priced “fairly and reasonably.” And, US officials noted over the summer that they expect insurance companies will not charge copays for COVID-19 vaccinations.
The cost of the vaccine for Medicaid enrollees is expected to vary by state. While Medicaid expansion states require complete coverage of ACIP-recommended vaccines without cost sharing, vaccine coverage is optional in non-Medicaid expansion states and remains up to the state’s discretion. However, through the Families First Coronavirus Response Act, all states are eligible for a temporary (through the end of the public health emergency) 6.2 percent increase to their Federal Medical Assistance Percentage (FMAP). One condition for states to receive this money is that the state plans must cover, without cost sharing, COVID-19 vaccinations.
For Medicare enrollees, vaccines are typically covered under Medicare Part D, which allows for cost sharing. The Centers for Medicare & Medicaid Services (CMS) can opt to cover the COVID-19 vaccine under Medicare Part B (which already covers the influenza vaccine and the pneumococcal pneumonia vaccine), a move that would prohibit cost sharing. As of mid-September, officials were still working with Medicare to figure out the cost to beneficiaries, but noted that the cost would likely not exceed $3.50 out of pocket per individual.
How will states monitor vaccine distribution?
The CDC is developing a Vaccine Administration Management System (VAMS) to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments. The system, funded by an almost $16 million sole-source contract, is designed to share data with existing Immunization Information Systems or immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients. As of Oct. 7, 2020, however, VAMS has not yet announced plans, leaving state leaders confused about how to plan for vaccine tracking. Concerns have been raised that VAMS might bypass state systems, leaving states unsure whether they will need to use the new system or be able to enhance their existing immunization registry systems in time.
Immunization registries – either VAMS, IIS or a combination of both – will be needed to record vaccination information, identify individuals in need of a first or second dose of a vaccine, remind individuals to get vaccinated, and track follow-up. One critical concern is whether immunization registries have the capacity to ensure that people receive a second dose of the vaccine within an acceptable timeframe and that they receive the same type of vaccine for both doses.
Historical underinvestment in IIS has resulted in wide variation across states’ IIS policies, size, and scope. They have different patient consent policies, reporting mandates, and data-sharing policies. In some states, provider participation in the IIS is mandated by law, and in other states participation is voluntary. As a result, only 55 percent of immunization programs have 95 percent or more of individuals in their jurisdictions registered in their IIS. There is also inconsistent communication between systems. Many electronic health record (EHR) systems are not connected to immunization registries, leaving individuals who receive vaccines at different locations with incomplete immunization records. Although some states receive matching funds available through the Health Information Technology for Economic and Clinical Health Act (HITECH) to enhance interoperability of electronic data exchange between EHR and immunization registries, many rely on the CDC, private foundations, and health care providers and insurers to fund their systems.
Because multiple COVID-19 vaccine doses are forecast to be required, strong data-sharing capabilities between registries also is critical. State IIS need to be able to talk to other health records systems and other states’ immunization registries in order to ensure that individuals receive the correct second dose at a different facility, and even in a different state if necessary. However, in 2018, only 10 percent of immunization registries had conducted at least one query of an IIS in another jurisdiction. While the need for better systems to distribute and monitor the COVID-19 vaccine is clear, because VAMS has not yet released plans, states are left to figure out whether and how to:
- Upgrade existing systems, which requires time and resources;
- Rely on a new system that will be unfamiliar to providers and clinics; or
- Use a combination of both.
How are states promoting public trust in the vaccine?
Vaccine hesitancy will also be a critical issue. According to a recent Pew Study, the number of adults who say they will get a COVID-19 vaccine has fallen from 72 percent in May 2020 to 51 percent in September. Another study found that 35 percent of Americans would not get a vaccine, even if it were free. Mistrust of health care is especially prevalent among Black communities, who are skeptical of the medical system because of current and past discrimination against people of color. This distrust continues as Black Americans are hit hardest by COVID-19, making it even more critical that the government finds ways to boost confidence in COVID-19 vaccine safety.
The need for standardized public health messaging during this pandemic is also clear. In fact, state officials noted that currently, clear and consistent vaccination messaging is one of the biggest issues that states need the federal government to address. Typically, states use a variety of mechanisms for disseminating vaccine information, such as partnering with community organizations, hospitals, and other state agencies to disseminate information to their constituents, sending out clinician letters to providers and pharmacists, and using IIS to send vaccine reminders to patients. These strategies will continue to be important when states market the importance of getting the COVID-19 vaccination.
At the same time that state officials are concerned about gaining and developing public trust in the vaccine, they also need to manage expectations about vaccine availability and efficacy. As noted, the CDC playbook asks jurisdictions to plan for three phases of distribution:
- During Phase 1, critical populations such as essential workers and high-risk individuals are prioritized;
- In Phase 2, limited doses will be available to the public; and
- In Phase 3, there will be sufficient vaccine supply for the entire population.
In several states, nursing home staff and residents make up nearly half of residents who have died from COVID-19, including 55 percent of deaths caused by the coronavirus in Massachusetts. While hospitals’ personal protective equipment (PPE) shortages have been highlighted, less attention has been paid to the critical need for PPE and infection control expertise at nursing homes. In response, states are launching rapid-response initiatives to assess and stabilize patients and provide infection control recommendations and support.
The COVID-19 pandemic is shining a light on well-established racial disparities in health care access and quality, and in social and economic factors affecting health status and outcomes. The racial inequities exposed by case identification and death rates data give states opportunities to improve their responses and interventions.
As state and local data becomes available, Louisiana and Illinois governors have highlighted racial disparities in COVID-19 cases and deaths. This aligns with governors’ recent public statements about equity – 22 governors mentioned the need for educational, economic, and social equity in their state of the state addresses earlier this year.
State public health agencies are working around the clock to inform the public about the pandemic by regularly monitoring and reporting data, which is one of their core functions. An analysis by the National Academy for State Health Policy (NASHP) of state public health websites found that 25 states (AL, AR, AZ, CA, CT, GA, ID, IL, IN, LA, MA, MD, MI, MN, MS, NY, NC, OH, OK, SC, TN, TX, VA, WA, and WI) and Washington, DC are reporting COVID-19 data by race and/or ethnicity.
Among the findings:
- Six states report case data (laboratory-confirmed positive cases), three report mortality data, and 17 report both cases and mortality by race and/or ethnicity.
- States use a variety of categories to report race and ethnicity data. For example, Louisiana reports race data for the following categories: American Indian/Alaska Native, Asian, black, Native Hawaiian/Pacific Islander, other, unknown, and white. Louisiana reports ethnicity data as either Hispanic/Latino or non-Hispanic/Latino. Connecticut reports Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic Asian, non-Hispanic other, and non-Hispanic unknown.
- Eighteen states report a large proportion of unknown (or missing) race/ethnicity.
- Fourteen states illustrate racial or ethnic disparities where the percentage of deaths or cases for one population is disproportionately high, compared to the demographic breakdown of the state. For example, Mississippi reported that 72 percent of its deaths from COVID-19 have been in the African American population, despite the fact that African Americans make up only 38 percent of the state’s overall population.
State health secretaries and legislators also are emphasizing the importance of identifying disparities to understand and respond to the pandemic and promote health equity. Recently, Massachusetts’ Health and Human Services Secretary, MaryLou Sudders said, “I want to be clear, obtaining racial and ethnic data on cases of COVID-19 is crucial for examining where and on whom the burden of illness and death is falling…It’s actually essential for the commonwealth response to the pandemic and important information for all of us to understand.”
There are additional opportunities for states to monitor and address COVID-19 disparities. Gov. Andrew Cuomo of New York has committed to collecting more comprehensive data about COVID-19 in minority communities. Publicly reporting COVID-19 testing, hospitalization, and recovery by race and ethnicity could further allow state and local policymakers, providers, and other stakeholders to monitor and ensure equity in access to resources for prevention and treatment in order to improve outcomes.
State and city leaders can harness COVID-19 data to tailor their current responses to the pandemic and continue to identify strategies to meet the health and health-related social needs of communities of color. States use race/ethnicity data in a number of ways, including targeting or soliciting funding, tailoring stakeholder outreach and engagement, informing public health initiatives, and strengthening governmental processes to address disparities strategically and comprehensively.
In response to data in her state, Gov. Gretchen Whitmer established the Michigan Coronavirus Task Force on Racial Disparities to develop recommendations for addressing disparities “right now as we work to mitigate the spread of COVID-19 in Michigan.” Task Force chair, Lt. Gov. Garlin Gilchrist II, tweeted, “COVID-19 is a constant reminder of how dangerous racial disparities and inequality are for people of color. 14% of our population is Black, but more than 40% of deaths are in Black communities. I’m working alongside @GovWhitmer to make Michigan a leader in addressing this.”
City leaders also are taking action. Chicago Mayor Lori E. Lightfoot announced a multi-pronged strategy to “address systemic health inequities within the COVID-19 crisis.” Specifically, the mayor in collaboration with nonprofit partners is:
- Establishing a Racial Equity Rapid Response Team to engage community members;
- Conducting regional briefings in targeted communities and with street outreach workers; and
- Calling for more detailed data collection.
Importantly, the city’s health department signed a public health order enhancing data-sharing requirements for certain facilities to support COVID-19 tracking.
States can incorporate lessons into their existing state initiatives to ensure access to coverage and address health equity through accountable health models, Medicaid managed care contract language for social determinants of health, unique data-sharing agreements, and workforce strategies. As the Coronavirus Aid, Relief and Economic Security Act (CARES Act) funding is made available to states and hospitals, leaders can use the funds to support communities and populations disproportionally affected by COVID-19 due to structural and social inequities. States’ efforts to address health equity will continue throughout and beyond this pandemic. NASHP will continue to track states’ public reporting of COVID-19 by race and ethnicity.
|States Publicly Reporting COVID-19 Data by Race/Ethnicity*|
|State||Data Reported||Categories Used to Define Race/Ethnicity|
|AL||Cases**||Race: Asian, Black, White, Other/Unknown
Ethnicity: Hispanic/Latino, Not Hispanic/Latino, Unknown
|AR||Cases and Mortality||Black, White, American Indian, Asian, Pacific Islander, Multiracial, Other, Missing|
|AZ||Cases and Mortality||White Non-Hispanic, Hispanic or Latino, Native American, Black Non-Hispanic, Asian/Pacific Island, Other Non-Hispanic, Unknown|
|CA||Cases and Mortality||Latinos, Whites, African Americans/Blacks, Asians, Multiracial, American Indians or Alaska Natives, Native Hawaiians or Pacific Islanders, Other|
|CT||Cases and Mortality||Hispanic, Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Asian, Non-Hispanic Other, Non-Hispanic Unknown|
|DC||Cases and Mortality||Race: Unknown, White, Black/African American, Asian, American Indian/Alaska Native, Other/Multiracial, Refused During the Interview
Ethnicity: Unknown, Hispanic or Latinx, NOT Hispanic or Latinx, Refused During Interview
|GA||Cases||Race: Black or African American, White, American Indian/Native American, Asian, Multiracial, Native Hawaiian/Pacific Islander, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Unknown
|ID||Mortality||Race: White, Black, American Indian/Alaska Native, Asian/Pacific Islander, Other Race/Multiple Race, Race Information Pending
Ethnicity: Non-Hispanic, Hispanic, Ethnicity information Pending
|IL||Cases and Mortality||White, Black, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Other, Left Blank|
|IN||Cases and Mortality||Race: White, Black or African American, Asian, Other, Unknown
Ethnicity: Not Hispanic or Latino, Hispanic or Latino, Unknown
|LA||Mortality||Race: American Indian/Alaska Native, Asian, Black, Native Hawaiian/Pacific Islander, Other, Unknown, White
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino
|MA||Cases and Mortality||Hispanic, Non-Hispanic White, Non-Hispanic Black/African American, Non-Hispanic Asian, Non-Hispanic Other, Unknown, Missing|
|MD||Cases and Mortality||African-American, Asian, White, Other, Data not Available|
|MI||Cases and Mortality||Race: American Indian or Alaska Native, Asian/Pacific Islander, Black or African American, Caucasian, Multiple Races, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Other, Unknown
|MN||Cases and Mortality||Race: White, Black, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Other, Unknown/Missing
Ethnicity: Hispanic, Non-Hispanic, Unknown/Missing
|MS||Cases and Mortality||Black or African American, White, Other|
|NY||Mortality||Hispanic, Black, White, Asian|
|NC||Cases and Mortality||Race: American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, Other
Ethnicity: Hispanic, Non-Hispanic
|OH||Cases and Mortality||Race: White, Black, Other, Unknown
Ethnicity: Non-Hispanic or Non-Latino, Hispanic, Latino, Unknown
|OK||Cases and Mortality||Race: American Indian/Alaska Native Only, Asian Only, Black Only, White Only, Other/Multiple Races
Ethnicity: Hispanic or Latino (can be any race)
|SC||Cases||Race: African American, White, Asian, American Indian or Alaska Native, Unknown, Other|
|TN||Cases||Race: White, Black or African American, Other/Multiracial, Asian, Pending
Ethnicity: Not Hispanic or Latino, Hispanic, Pending
|TX||Cases||Asian, Black, Hispanic, Other, Unknown, White|
|VA||Cases||Race: Black or African American, White, Other, Not Reported|
|WA||Cases and Mortality||Hispanic, Non-Hispanic American Indian or Alaska Native, Non-Hispanic Asian, Non-Hispanic Black, Non-Hispanic White, Non-Hispanic Native American or Other Pacific Islander, Non-Hispanic Multiracial, Non-Hispanic Other Race, Unknown|
|WI||Cases and Mortality||Race: American Indian, Asian or Pacific Islander, Black, White, Multiple or Other Races, Unknown
Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Unknown
*As of April 12, 2020. View an updated interactive map highlighting state efforts to track COVID-19 case and death rates by race and ethnicity here.
** Cases in this table refer to laboratory-confirmed positive COVID-19 cases.
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.
As coronavirus (COVID-19) hospitalizations and ICU bed demand surge across the country, 13 states have quickly acted to implement temporary, targeted suspensions of their certificate of need (CON) requirements for construction or expansion of new health-care facilities to remove regulatory barriers to address this critical health care need.
CON laws are state regulatory mechanisms to help determine whether building or expanding health care facilities and services in a given area is needed. Currently, 35 states have CON statutes. Generally, a health care facility submits a CON application to a state agency when it proposes to build an additional health care facility, provide a new lines of services, or increae the number and type of beds it offers. The state then reviews and determines whether to approve the proposed change.
A central assumption behind state CON legislation is that overbuilding and redundancy in health care facilities leads to higher health care costs. As a result, CON requirements can be useful tools to achieve health care cost containment. However, states are also working to ensure these cost containment tools do not inadvertently create barriers in their response to the COVID-19 crisis.
Thirteen states have taken steps to mitigate these potential barriers. Twelve state governors (CT, GA, IN, IA, LA, MD, MI, NJ, NY, SC, TN, and VA) have issued executive orders that suspend their states’ CON requirements. These suspensions are temporary and targeted:
- They last only for the duration of the public health emergency in their respective states; and
- Authorize suspensions of CON requirements only to the extent needed in order to respond to COVID-19.
Vermont enacted legislation on March 30, 2020, to provide authority to the Green Mountain Care Board to waive CON requirements.
Six states (GA, MD, MI, NY, VT, and VA) have temporarily expedited their CON approval process, but have not suspended it outright. For example, since Maryland Gov. Larry Hogan’s March 5, 2020, emergency declaration, which included a general authority allowing the Health Services Cost Commission to waive its CON statute and regulations as necessary to respond to COVID-19, the commission has granted seven expedited emergency CON applications within one to two days of their receipt. One expedited approval allows for the creation of two intensive care units, one containing 48 beds, by converting a conference room and office space, which can be re-assembled after the current state of emergency ends.
Another expedited approval allows conversion of a former nursing home and existing business center into 72 lower-acuity beds. The commission has also suspended the need for any applying facility to file a formal CON application until 30 days past the end of the emergency declaration. These emergency CONs will remain in effect for a maximum of 165 days or until 30 days after the termination of the state of emergency.
Similarly, Vermont’s Green Mountain Care Board recently issued guidance outlining an expedited review process. Applications for an emergency CON must include a description of how the project will support or enhance the state’s ability to manage the COVID-19 emergency. The board will review applications without the typical public notice or holding a public hearing and must issue a verbal decision within 24 hours. An emergency CON will only be effective until the public health emergency has lifted, then applicants will need to re-apply for a CON under the non-emergency process.
Michigan’s temporary suspension of CON allows its Department of Health and Human Services to issue an emergency CON necessary to respond to COVID-19 without following the statutory procedural requirements. Virginia’s executive order similarly authorizes its
|State Suspensions of their Certificates of Need (CON)|
|State||Executive Order||Legislation||Suspension Expires when Public Health Emergency Terminates||Expedited CON Approval Available||Written Notice by Facilities to State – No Prior Approval Required||State Has Plan to Return Capacity to Pre-Emergency Levels|
|Maryland||X||30 days after termination of the emergency||X||X – Will permit retention of additional capacity for good cause.|
commissioner of the Department of Health to approve any increase in hospital or nursing home bed capacity needed as a result of COVID 19 – its CON regulatory requirements notwithstanding. New York’s Commissioner of Health is also authorized to approve temporary changes hospitals need to make in response to an increase in patients needing a bed without following the traditional CON procedural requirements in order to respond to COVID-19.
Georgia’s Executive Order suspends its CON statute and rules in cases where such suspensions would permit capable facilities to expand capacity, offer services, or make expenditures necessary to assist with the needs of the public health emergency. In order to implement this, Georgia’s Department of Community Health (DCH) is requiring heath care facilities to submit written requests for suspensions of specific provisions of the CON statute and a description of the changes they seek to make. DCH is also requiring written reports confirming the actions health care facilities have taken to assist, aid, or cope with the emergency, as well as a final reporting to be provided upon the expiration of the emergency. DCH will accept these reports for 90 days following the end of the public health emergency.
No Prior Approval Required
Two states, Connecticut and New Jersey, are allowing facilities to make relevant changes that would have required CON approval without first obtaining prior approval, so long as they report the changes in writing to the regulating authority. In Connecticut, hospitals and outpatient surgical facilities that would previously have sought a CON waiver for a temporary increase in bed capacity or to temporarily suspend services now have to notify the department about the temporary increase in licensed bed capacity or suspension of services in writing.
Similarly, in New Jersey, prior department approval of temporary waivers for exceeding licensed bed capacity, bed additions, physical space requirements or changing staff qualification requirements is no longer required. New Jersey inpatient facilities that make relevant changes in response to COVID-19 are required to provide written reports to the department about which if any of the actions were taken, the duration of the implementation, and any adverse outcomes attributable to them.
In Iowa, South Carolina, Indiana, Louisiana, and Tennessee, the temporary CON suspension guidance has been more general, indicating only that these states suspend statutes and/or regulations implementing CON laws to the extent necessary to allow hospitals to temporarily increase their beds at an existing location or establish new locations, to the extent these are necessary for the treatment of COVID-19 patients. Indiana’s CON law and its emergency waiver from those requirements apply only to nursing facilities.
Similarly, Louisiana’s Facility Need Review (FNR) process applies to adult residential care facilities, home- and community-based service providers, adult day health care, hospice providers and behavioral health services. Louisiana has suspended its Department of Health’s requirement to review all FNR applications within 30 days as a means to reduce workload for LDH staff that have unprecedented other duties.
What Happens When the Crisis Abates?
CON structures that are elastic enough to permit the easy expansion and contraction of health care capacity are useful for both addressing public health emergencies and as ongoing state tools to monitor health care capacity, need, and cost. Consistent with this approach, Connecticut, Maryland, and New Jersey have indicated how or whether capacity and services will be expected to return to prior levels after the current crisis abates. Connecticut requires that any hospital wishing to retain the additional beds or suspend particular services established during the emergency will have to file a CON application consistent with the established statutory and regulatory process.
Maryland will allow extensions of the emergency CON granted beyond the end date for good cause shown, although there is no current guidance as to what criteria will be considered in that determination. New Jersey will require that once the emergency is mitigated, inpatient facilities must return to previously licensed capacity and operate within all licensure standards. These are important considerations for states, given that unneeded capacity can contribute to high health care costs and states will likely be balancing health care costs and lower revenue streams in the coming months.
As additional states consider loosening CON requirements or extending their emergency declarations in order to respond to COVID-19, they may consider framing CON suspensions in a manner that:
- Permits quick action;
- Is targeted to waive only those provisions necessary to respond to COVID-19;
- Is temporary – lasting only for the duration of the public health emergency;
- Provides a process to reduce capacity back to pre-emergency levels; and
- Providing an avenue for determining whether there is sufficient justification to retain the additional capacity created during the emergency.
During this public health emergency, new federal laws (HR 6201, HR 748) are making significant steps to eliminate consumer cost-sharing for coronavirus (COVID-19) testing, diagnosis, and prevention while states are working to increase insurance access and surprise billing protections.
The recently passed Families First Coronavirus Response Act includes several provisions that expand the ability of Medicaid and the Children’s Health Insurance Program (CHIP) to cover COVID-19 testing and testing-related services with no out-of-pocket cost to consumers. The law also includes an option allowing states to extend Medicaid coverage to uninsured individuals for testing and testing-related services. States’ medical and administrative costs for this will be fully matched by the federal government.
However, high costs associated with medical treatment pose significant challenges for the millions of uninsured and underinsured individuals across the country, and these measures may not protect Americans from costs associated with treatment and management of the virus, including prescription drugs, physicians’ visits, hospitalizations, and specialty care. Consumers need health coverage to ensure there is no barrier to receiving the care they may need.
As the pandemic worsens, state agencies are taking action to maximize access to coverage, including private insurance, as one means to protect consumers from the severe financial burden that may result from necessary medical care. This includes increasing access to qualified health plans (QHPs) sold through the health insurance marketplaces. Under requirements set by the Affordable Care Act (ACA), QHPs must cover essential health benefits, including emergency room services, hospitalizations, prescription drugs, preventive services, and mental health services critical to combatting and managing the outbreak. QHPs also must follow cost-sharing restrictions, including the provision of preventive services at no out-of-pocket cost, and the prohibition on annual and lifetime limits on spending.
State-based marketplaces (SBMs) are working diligently to leverage available flexibilities to ensure that consumers in their states are able to enroll in and maintain QHP coverage. Eleven SBMs have opted to open temporary special enrollment periods (SEPs) so uninsured individuals can apply for coverage. This is in addition to actions taken by all SBMs to promote other SEPs available to consumers, including an SEP trigged by loss of minimum essential coverage (such as employer-sponsored coverage).
SBMs are rapidly tweaking tools, outreach strategies, and operations to ensure optimal customer service while also taking steps to comply with physical distancing guidance issued by state public health officials. DC Health Link, in Washington, DC, has created a table to educate consumers about how COVID-19-related services are covered under their health plans. Nevada Health Link has provided a comprehensive listing of state and federal resources available to consumers. Several SBMs are also coordinating closely with insurers who can leverage payment and grace period deadline extensions to help ensure consumer coverage is not disrupted during the pandemic.
In addition to increasing access to coverage, states are also moving forward to enact protections against the practice of surprise balance bills, or unexpected medical bills usually received because an enrollee unknowingly received out-of-network care. Surprise billing laws foremost seek to protect consumers from paying extreme bills incurred when they receive out-of-network services either unknowingly or because there was no other choice of provider or facility. Surprise billing protections will be even more important to ensure that consumers are protected from unprecedented costs in the event they require COVID-19 treatment.
Health systems are rapidly changing in response to the pandemic – states are setting up make-shift clinics, expanding telehealth services, authorizing more providers to be reimbursed for services, and relaxing provider licensing requirements. Many of these actions are necessary to increase provider capacity to meet the rapidly accelerating need for emergency health care services. However, insurers typically operate by only covering care administered by a limited network of providers. And, in some cases, insurers may include a facility, such as a hospital, in their network, but not actually cover all the providers who work there or services performed at that facility — including specialists or laboratory services. Even in normal circumstances, these situations leave insured individuals vulnerable to surprise medical bills. As states rush to expand health care capacity and consumers have increased urgency to seek care, consumers are increasingly susceptible to receiving care from an out-of-network provider or at an out-of-network facility.
Under the ACA, insurers are required to cover out-of-network emergency services as if delivered in-network. That same protections does not extend outside of an emergency setting, though several states have passed laws to protect consumers from surprise bills, including those incurred when a consumer had no other choice of where to receive treatment.
Recently, on March 18, 2020, Maine took emergency action to enact LD 2105, which incorporated surprise billing protections in the case of emergency services into state law. The law also includes billing protections for uninsured individuals as well as those covered by self-insured plans.
In Virginia, SB 172 has been sent to the governor. Like Maine’s law, the bill incorporates protections in the event of emergency care into state law. The bill also adds new protections in the case of out-of-network surgical or ancillary services provided at an in-network facility.
Without additional federal action, states will continue to take the lead in doing what is best for their citizens, including finding innovative strategies to ensure individuals have the best possible access to available services, while also protecting them from undue financial strain. The National Academy for State Health Policy will continue to monitor and report on the situation as it evolves.