Despite COVID-19 workarounds, such as telehealth and virtual recovery programs enabled by flexible federal guidelines, more than 40 states have reported increases in drug overdoses during the pandemic, underscoring the importance of keeping state harm reduction programs as accessible as possible.
As COVID-19 upends the nation’s health care systems, treatment for substance use disorder (SUD) has shifted to telehealth environments and recovery programs have gone virtual as state and federal policymakers adjust regulations and guidance to maintain access to services. But the unique risks facing people with SUD during this time of isolation and mandatory social distancing are also becoming more clear.
State-authorized harm reduction programs that provide syringe exchange services, testing for infectious diseases and referral to treatment, and connections to treatment for opioid use disorder and other SUDs provide a critical intervention. Despite the challenges of implementing COVID-19 protocols for what have traditionally been in-person services, states have developed flexibilities and innovative approaches to ensuring that these programs continue to provide critical, ongoing support to people with SUD until they are ready for treatment.
State guidance for harm reduction providers in response to COVID-19:
The guidance that state officials and agencies have developed recognize the unique challenges that face harm reduction providers during the COVID-19 pandemic. Many states acknowledge harm reduction as an essential service and some have temporarily loosened program restrictions to ensure the continuity of services during the pandemic.
- The Oregon Health Authority (OHA) authorized its Syringe Service Programs (SSP) to provide curbside services and phone orders for syringes, naloxone, and other supplies. OHA also suggested operational shifts in staffing, distancing protocols, and volunteer management to mitigate COVID-19 transmission among staff, volunteers, and clients. OHA included messaging in support of people who use drugs (PWUD) in order to maintain their safety during the pandemic. The messaging emphasized the increased respiratory risks associated with drug use and COVID-19 and provided guidance on how to reduce the risk of COVID-19 infection as well as the risk of overdose during the pandemic.
- In Maine, Gov. Janet Mills issued an Executive Order on March 30, 2020, suspending an existing one-to-one syringe exchange rule, thereby increasing the number of syringes individuals can take home at once. The order also allows flexibility in mail delivery services, needle exchange site locations and operational hours and provided on-site social distancing protocols.
- The Missouri Department of Mental Health issued comprehensive COVID-19 guidance in mid-March, which featured published resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Harm Reduction Coalition, and the National Health Care for the Homeless Council (NHCHC), as well as best practices from other states and programs. Missouri’s guidance includes operational directives for treatment and harm reduction providers, as well as practical harm reduction guidance for PWUD, particularly individuals who use drugs alone.
Adaptations in harm reduction services:
Harm reduction programs are making policy shifts to develop practices that respond to the specific needs of their communities. As states and municipalities have responded to the COVID-19 pandemic at varying degrees of restrictiveness, harm reduction programs have also tailored their programs to respond to the pandemic.
- Operational changes. Programs in Washington and other states have shifted services outdoors. They now provide curbside or mobile services and have closed their fixed sites entirely and instead rely on delivery services. Many Washington State SSP programs have limited hours and scope of services. In New York, SSPs have been operating with skeletal staff and reduced resources. In response to the new limitations on in-person service, 22 of 23 of New York’s SSPs now rely on some form of peer-delivered syringe services.
- Shifts in testing priorities. In addition to continuing to provide harm reduction services, some SSPs in Washington now provide COVID-19 screening and testing at their program sites. West Virginia’s harm reduction programs have reduced the amount of non-COVID-19 infectious disease testing they’re conducting and the amount of hepatitis A and B immunizations they administer, in order to focus on COVID-19 and the immediate needs of individuals with SUD.
- Emphasizing naloxone distribution. As overdose rates continue to rise during the pandemic, states are increasing access to the overdose-reversal drug naloxone. Pennsylvania’s Secretary of Health signed an updated standing order that allows community organizations to distribute naloxone through mail. Ohio’s Department of Mental Health and Addiction Services has provided official guidance to all community programs through its statewide Project DAWN overdose reversal initiative to maintain minimal contact with individuals who need services while maximizing naloxone distribution as a strategy to mitigate overdoses. Additionally, the US Department of Health and Human Services has published guidance for first responders to safely administer naloxone during the pandemic.
As states begin to consider the impact of COVID-19 on their budgets, programming, and future planning, maintaining harm reduction programs may become more challenging. Harm reduction programs are often supported by multiple funding streams, and program administrators and policymakers may consider leveraging federal grants and other non-state funds to maintain these services. In addition to ensuring access to infectious disease prevention and life-saving treatment and recovery services, harm reduction programs offer a mechanism to maintain engagement with people who have SUD and reduce their risk of overdose, which results from isolation.
This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for foundation purposes notwithstanding any copyright notation hereon.
Disparities in states’ COVID-19’s health outcomes have driven home the need for policymakers to reassess their work to advance racial equity and redirect efforts to be more effective. A recent update to the National Academy for State Health Policy’s (NASHP) interactive map, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, reveals that more than half of all states are now actively engaged in advancing equity in their COVID-19 responses and beyond.
As the pandemic progresses and reveals the disproportionate impact of the disease on people of color, several states have created task forces and workgroups to ensure the equitable distribution of testing, personal protective equipment (PPE), and information about the disease. Some states are funding these efforts to better achieve equitable health outcomes for communities of color.
In Maine, for example, Black Mainers represent about 1.4 percent of the total population, but over 22 percent of the COVID-19 cases whose race is known. Gov. Janet Mills announced that $1 million from the Coronavirus Relief Fund would be dedicated to expanding services like testing, case investigation, contact tracing, and education to help reduce the disproportionately large racial and ethnic disparities in COVID-19.
As the recommendations and findings from the state task forces are published, one theme that emerges is the need for states to engage with communities and prioritize the needs they identify. The examples below underscore a critical lesson that states have learned from COVID-19 – their prior strategies to advance equity were not sufficient and integrating community feedback is essential to forge new and effective strategies. These recommendations reflect the importance of involving communities and people of color in states’ long-term policies:
- In New Hampshire, the COVID-19 Equity Response Team released its initial Report and Recommendations in which they described the need for proactive community engagement, working toward an ideal of co-creation and community ownership.
- In Oregon, the Equity Framework in COVID-19 Response and Recovery features a commitment to make community-informed policy and forge partnerships by engaging with community leaders who should be an essential part of the decision-making process.
- In Washington State, proposed recommendations from the Governor’s Interagency Council on Health Disparities include the provision of opportunities for communities to take the lead in creating information about and for themselves, including through contracts and grants.
- In Virginia, Gov. Ralph Northam announced a pilot program in Richmond to increase equitable access to PPE in underserved communities that may be more adversely impacted by the COVID-19. The pilot program includes community engagement events and training on cultural humility and implicit bias for city personnel who engage with the community.
The themes of including communities in decision-making and in the crafting of emergency responses are reflected in state funding streams as well, with some states providing funds to community groups. The Utah COVID-19 Community Task Force created a multicultural subcommittee that oversees the COVID-19 Racial Equity & Inclusion Grant Fund. The fund provides grants up to $5,000 to community-based organizations that provide emergency assistance to multicultural communities. In Michigan, $20 million was made available to the Coronavirus Task Force on Racial Disparities to respond to community needs associated with the disparate impacts the virus has had on communities of color. Community groups were able to apply for the funding through the Rapid Response Initiative, with funds available for a wide range of needs.
As states continue to work towards equitable health outcomes and look for ways to counter a long history of systemic racism, several are focusing on children’s health as a way to address disparities and potentially influence health trajectories in the future. For example:
- New Hampshire’s Equity Response Report recommended Adverse Childhood Experiences (ACEs) as an area to explore to continue understanding and serving communities of need in New Hampshire, specifically communities of color, at both the state and local levels.
- Ohio’s COVID-19 Minority Health Strike Force Blueprint highlights strategies to improve health outcomes and advance equity for children, including strengthening early childhood education and specifically ensuring that K-12 chronic absenteeism reduction efforts meet the needs of children of color. Ohio’s Plan to Advance Equity highlights how childhood poverty disproportionately affects African American and Latinx children in Ohio. To address this, the governor established the Office of Children Services Transformation within the office of Children’s Initiatives and is investing $675 million to assist students’ wellness and success.
The COVID-19 pandemic is far from over, and the effectiveness of these strategies will be evaluated based on how well they reduce disparities in COVID-19 outcomes and the advancement of health and social equity beyond the pandemic. NASHP will continue to engage states in identifying promising practices and will provide tools and support as states implement their task force and workgroup recommendations and measure change and success over time.
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.
While the federal COVID-19 public health emergency – which allows for a range of state and federal policy flexibilities in programs such as Medicaid – was recently extended, considering the significant number of pandemic-related policies that states have implemented, officials need to begin preparing now for the eventual end of the emergency. Currently, there is little federal guidance about how states would unwind the many policy changes they have implemented in response to the pandemic.
MACPAC recommended that federal officials should provide states with a minimum 90-day advance notice of the PHE’s termination, and that federal guidance about returning to regular processes should be provided to states as early as possible.
One of states’ key concerns is disenrolling individuals from Medicaid who may have become ineligible during the PHE. This is because the Families First Coronavirus Response Act (FFCRA) provided enhanced federal Medicaid matching funds tied to maintenance of effort (MOE) requirements that include a prohibition on terminating Medicaid coverage of individuals who were enrolled as of or after March 18, 2020. To comply with that requirement, often referred to as the “continuous coverage” provision, states are not fully processing their traditional Medicaid renewals. The purpose of this MOE requirement is to help prevent coverage disruptions, particularly at a time when consumers may be especially in need of coverage, yet also experiencing extreme fluctuations in income.
Although the increase in federal Medicaid funds provided by the FFCRA and the other MOE requirements do not expire until the end of the quarter in which the PHE ends, the continuous coverage provision ends on the last day of the month of the PHE. However, due to a number of reasons, states will not be able to immediately return to the regular processing of eligibility renewals. As noted by MACPAC, restarting these processes will require states to collect new information about enrollees’ income and other criteria to re-verify eligibility. To do so, states will need to make a number of eligibility system, policy and process changes.
States have emphasized the need for flexibility when reinstating eligibility redeterminations. For one, changes will need to be implemented within the context of strained state administrative capacity due to budget cuts, staff furloughs and reassignments to other departments to respond to COVID-19, early retirements, hiring freezes, and the need to focus on addressing increased demand for state-supported services. States also have different IT systems for determining Medicaid eligibility, each with distinctive programming challenges. This is further complicated by the fact that systems must be coordinated, and in several cases fully integrated, with health insurance marketplaces, a major vehicle through which consumers may seek Medicaid and marketplace coverage. Given these complications, states have expressed the need for a “menu of options” from the Centers for Medicare & Medicaid Services (CMS) detailing how to phase out the changes put in place during the PHE. Requirements for notifying enrollees about program and eligibility changes also vary by state, and states need time to develop notices and send out information to both individuals and providers about coverage changes.
Another important issue is that because the renewal process is currently backlogged, it could overwhelm states if federal officials require them to go back and process redeterminations for individuals with renewal dates that have already passed. In anticipation of the eventual end of the PHE, some states have been continuing to send out renewal notices to enrollees to gather and assess their information. In these states, coverage for eligible individuals is extended and while no action is taken to disenroll those who appear to be ineligible, they can be identified for follow-up at the end of the PHE. But many state officials have indicated that it would be helpful if federal guidance instead allows them to focus on moving forward with a rolling renewal date process when the PHE expires.
Colorado’s Department of Health Care Policy & Financing recently sent a letter to CMS administrators requesting certain federal actions to help it plan for the end of the PHE. Specifically, the state asked that CMS provide at least 60-days notice before the end of the PHE, and allow at least 90 days after the end of the PHE to conduct redeterminations and inform enrollees and providers about the associated changes — and it indicated that even more time may be needed if the PHE is extended beyond October because Medicaid enrollment will likely continue to increase over time. Similar to MACPAC, Colorado also stressed the importance of CMS providing specific guidance about redetermination requirements, and they requested additional guidance about aligning redetermination time frames between CHIP and Medicaid. Because Colorado’s pause on processing renewals in CHIP was implemented through a state plan amendment (SPA), its CHIP policies expire on the day that the PHE ends, as opposed to the Medicaid continuous coverage provisions, which expire on the last day of the month in which the PHE ends.
Colorado’s letter also emphasized that the state has at least 40 Medicaid projects and 65 home- and community-based services items that will need to be modified when the PHE expires. Some of these efforts will involve significant changes in claims processing and eligibility systems that will take time to implement and increase the workload of eligibility technicians. Some of the other issues that the state is seeking guidance on from CMS include:
- Whether states will have flexibility to stagger redeterminations and renewals after the end of the PHE to reduce the workload burden; and
- Whether federal Medicaid funding will be available for enrollees for whom the state is conducting redeterminations on for beyond 90 days if the state needs more time, as well as through any disenrollment appeals processes.
The letter also raised an issue that has been expressed by state-based marketplace (SBM) officials in other states — that states will need time to develop messaging and provide assistance to individuals who are no longer eligible for Medicaid in order to help them enroll in marketplace coverage. Many SBM officials are concerned that once the PHE ends, they may face an unmanageable influx of individuals transitioning from Medicaid to marketplace coverage. As federal officials develop guidance, they should take this issue into consideration and also factor in the timing of SBMs’ open enrollment periods.
In addition to eligibility redeterminations, states will also need sufficient time and federal guidance to unwind other policies implemented during the PHE, such as Section 1135 waivers that eased many provider-related requirements and validations, and Medicaid and CHIP disaster relief SPAs to facilitate enrollment or waive cost-sharing requirements. Another factor is that some states may be interested in retaining certain policy flexibilities implemented under the PHE, and as identified by MACPAC this will require states to take a number of steps to make these changes permanent.
States will also need guidance about resuming many federal reporting requirements that were put on hold during the PHE. Given the pandemic’s wide-ranging effects on coverage and care access, state Medicaid and CHIP officials have expressed concerns about how to determine baseline data for quality measures and provide information for other regular program integrity assessments. They indicated that they hoped CMS would allow flexibility in 2020 and 2021 federal reporting and auditing as states make good-faith efforts to come into compliance. SBM officials have expressed similar concerns about the potential of being penalized for certain policy choices and the need for federal recognition of the unique programmatic and operational challenges created by the pandemic.
As highlighted by MACPAC, “Delayed guidance, unrealistic expectations, or short implementation time frames for eligibility redeterminations and provider revalidations could disrupt state operations, result in beneficiaries churning on and off of Medicaid coverage, and jeopardize access to care.”
Although the PHE was extended again, states still face significant challenges without sufficient information from the federal government about how to transition back to regular operations. States urgently need formal federal guidance so they can begin effective and efficient planning efforts now, both to reduce administrative burdens and minimize disruptions in coverage and care.
Direct care workers play a critical role in the success of states’ long-term services and supports (LTSS) systems, but faced with COVID-19, low wages, and few advancement opportunities, states struggle to retain this workforce. Recently, state leaders came together virtually at National Academy for State Health Policy’s annual conference to share strategies to improve recruitment and retention of these workers.
Today, personal care attendants, home health aides, and nursing assistants are on the frontlines, providing care to older adults and people with disabilities. COVID-19 has made direct care work one of the most dangerous professions, while putting an enormous strain on family caregivers and state budgets.
Even prior to the pandemic, states faced a significant direct care workforce shortage due to the low wages and limited advancement, which has contributed to high turnover. The pandemic has exposed other vulnerabilities – nearly six out of ten direct care workers are people of color and almost half live in low-income households.
Tennessee Promotes Workforce Retention
In 2013, the TennCare (Tennessee Medicaid) Long-Term Services and Supports (LTSS) division held listening sessions throughout the state and found that Medicaid enrollees’ quality of life hinged on the quality and consistency of their LTSS workers. That insight led state officials to create a value-based workforce strategy for direct care workers. Using a State Innovations Model (SIM) grant from the Centers for Medicare & Medicaid Services (CMS), the state incorporated workforce recruitment and retention into its value-based payment strategy, and worked across state agencies to implement and incentivize career and educational opportunities for direct care staff.
In consultations with national experts, the state developed a competency-based training program using evidence-based best practices in adult learning. Corresponding with CMS Direct Support Workforce Core Competencies released in 2014, the training uses an online format combined with work-based learning to provide an opportunity to acquire shorter-term credentials with clear labor market value.
Officials from TennCare worked with the Tennessee Board of Regents to award college credit and a post-secondary credential (certificate) for completion of the training. This curriculum is embedded within a variety of existing (and potential new) degree paths through the Tennessee Community Colleges and Colleges of Applied Technology. The state was also able to leverage Tennessee Promise and Tennessee Reconnect funds to defray tuition costs for adult learners, and plans to provide incremental raises to direct care staff who complete the training once the state weathers COVID-19-related budget shortfalls.
At the same time, TennCare has begun to transition its LTSS system to a value-based payment model. Staff training, retention, and job satisfaction are key measures in the state’s quality framework and tied to LTSS provider reimbursement. By aligning Medicaid payment, investments in workforce training, and the state’s higher education goals and resources, Tenncare has established a clear education and career pathway that will help it grow and retain its direct care workforce.
Oregon’s Home Care Workforce Unionized
Because of the relationship between direct care workers and quality of care, the state created the Oregon Home Care Commission, a semi-independent state commission that supports home care workers, personal support workers, and consumers/employers by:
- Defining qualifications of home care and personal support workers;
- Providing a statewide registry of these worker that matches individuals needing in-home care with home care workers;
- Providing training opportunities; and
- Serving as the “employer of record” for collective bargaining for home care and personal support workers who receive service payments that are from public funds.
The Service Employees International Union (SEIU), represents Oregon’s in-home workforce. Full-time equivalent in-home workers must earn an income above the poverty level for a family of four in Oregon. They have health benefits (for 40 hours of work per month) as well as leave time for vacation, sick time, and COVID-19. They also receive training and personal protective equipment (PPE).
The state funds Oregon Care Partners, an education resource that provides in-person and online classes to help family and professional caregivers build the knowledge and skills needed to improve the quality of life of older adults and people living with Alzheimer’s in Oregon. These classes are available to anyone living or working in Oregon and are offered free of charge. Classes include COVID-19 infection control, supporting individuals with Alzheimer’s/dementia, supporting individuals with challenging behaviors, cultural competency, and more.
Oregon’s support of its direct care workers through living wages, sick and vacation benefits, training, and a registry that matches these workers with individuals needing home care helps not only this important workforce but also care recipients and their families. This support has been an important strategy in this state’s longtime effort to successfully rebalance its LTSS system toward home and community-based services.
Both Tennessee and Oregon have had to respond quickly and with enormous flexibility to the challenges presented by the pandemic, maintaining LTSS services through strategies such as provider rate increases and retainer payments, new infection control protocols, and additional protections and benefits for LTSS staff.
While cascading effects of both COVID-19 and state budgets make ongoing investments in the direct care workforce incredibly challenging, the experience of the past few months has also opened up new opportunities: Medicaid waiver flexibilities and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and state funding allowed states to increase payments to stabilize and incentivize the LTSS workforce to maintain care to some of the most vulnerable populations during the pandemic. Telehealth has been transformational. Certain services, such as therapies, care management, and adult day health, moved from face-to-face to virtual encounters. Some states used additional pandemic-related money to provide childcare for essential workers.
As a result of these unprecedented changes, state officials are rethinking how LTSS is delivered, where, and by whom. The future direct care workforce will likely need additional training on managing the spread of infectious disease, delivering care through telehealth and other virtual modalities, and engaging families as critical partners on the care team. State health policymakers may also want to invest in the LTSS workforce as another opportunity to address racial equity within state-funded healthcare systems. While it is too soon to tell which of the many changes wrought by the pandemic in state LTSS systems will be sustained, one thing is certain, as noted by a state health official during the NASHP conference: “Medicaid will never look the same after COVID.”
This conference session and blog is one component of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, which is funded by The John A. Hartford Foundation in collaboration with the Administration for Community Living.