Hospitals and health care providers need financial support to respond to the pandemic and for future viability. In response, Congress allocated billions of dollars in relief funds through multiple existing and new programs. The disbursement of these funds is uncoordinated and so are public reports that track where the money is going, but states need to know how much these health care systems are getting.
People with substance use disorders (SUD) who are experiencing housing instability or homelessness are particularly at risk during the COVID-19 pandemic, leaving states challenged more than ever to identify effective housing strategies that can simultaneously address the complex treatment needs of people with SUD while also curbing the spread of COVID-19 in congregate settings.
COVID-19 has affected nearly every aspect of American life, including access to health insurance coverage, which is critical during a pandemic. Job losses and reductions in hours have resulted in millions losing employer coverage or the income needed to pay premiums, forcing them to join the already sizeable ranks of the uninsured. State marketplaces have stepped in to make sure previously uninsured individuals and those losing coverage have a source of coverage.
COVID-19 has profoundly affected the health care landscape, raising anew concerns about the high cost of hospitalizations while simultaneously placing new burdens on those facilities and curtailing non-emergency services. Providers, unable to see patients for routine care, lost revenue and many free-standing physician practices are now at risk, and now face increasing pressure to merge with large health systems to survive.
The importance of COVID-19 testing is clear, especially as new cases climb dramatically, reversing earlier successes at controlling the spread of the disease. Lack of a coordinated, federally-led testing initiative and protocols has prompted questions about how often testing should occur, whether both symptomatic and asymptomatic should be tested, and who should pay for it, and in what circumstance.
As states implement their re-opening plans, public health experts recommend increased access to COVID-19 testing and contact tracing before communities return to work and school. The federal government’s Guidelines for Opening Up America Again and Blueprint for Testing Plans and Rapid Response Programs provide limited guidance, and identify states as responsible for developing testing plans and rapid response programs.
Federal guidance recommends that:
- Every symptomatic patient should receive a timely and accurate test.
- Selected monitoring of rates should occur at senior and congregate living settings, federally supported health care clinics, and other high-priority locations identified by states, such as food processing plants. Priority should be given to underserved, urban and tribal settings.
- Antibody tests should be available for first responders, essential workers, health care providers, and vulnerable populations.
- Federal guidelines also suggest states not begin reopening their economies and loosening stay-at-home orders, etc., until there is a downward trajectory of documented cases, or a downward trajectory of positive tests (as a percent of total tests) within a 14-day period.
However, there is no nationally recognized, evidence-based testing protocol available for states and/or employers to adapt or model their own testing approaches on.
What should the frequency of testing be to safely re-engage staff and open a business? Importantly, guidance to date does not address testing the asymptomatic, yet research shows they can transmit the disease – an issue of mounting importance to employers and school officials as they contemplate when and how to resume classes. Confidence in a testing protocol could alleviate concerns for educators and families, paving the way for a thoughtful approach to schooling youth, which would also allow parents more freedom to go back to work.
Other countries have shown that case identification and contact tracing are vital to limiting the spread of COVID-19. Experts recommend that the United States should conduct more than 900,000 tests a day, with the goal of reducing the positive rate to less than 5 or 10 percent before reopening. On June 22, 2020, the COVID Tracking Project reported 464,758 new tests performed nationwide, and the Centers for Disease Control and Prevention (CDC) reported a positive testing rate of 10 percent.
The combination of testing and contact tracing can help identify other potential individuals infected with COVID-19 before it can spread further. Experts recommend that rapid diagnostic testing, contact tracing, and the ability to isolate new cases are important rapid response operations. Research shows that these testing, contact tracing, and isolation strategies are more effective at reducing transmission than social distancing alone, and are essential for economic and social activities to resume. Congress recently allocated $11 billion to the CDC to support state, local, and tribal governments to expand testing. Participating jurisdictions will submit a plan to the Department of Health and Human Services that includes testing goals, monthly estimates of laboratory and testing capacity, and a description of how the resources will be used for testing and community mitigation policies.
The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security Act (CARES Act) also allocate funds to expand the availability of COVID-19 testing with the intention that individuals can access testing for free. Through these laws, Congress earmarked dollars within provider relief funds for testing and treatment for the uninsured and created a new Medicaid COVID-19 testing eligibility group that can be implemented as a state option. The laws also include requirements that group health plans and individual insurance cover COVID-19 testing with no cost-sharing or medical management requirements, such as prior authorization.
Health insurers are required to cover tests “when medically appropriate for the individual, as determined by the individual’s attending health care provider.” An attending provider is defined by federal guidance as a licensed provider, practicing within the scope of his/her license, who has made an individual clinical assessment to determine if a COVID-19 test is necessary, but does not need to be “directly” responsible for a patient’s care. In keeping with the intent to expand testing, insurers are required to adopt this looser standard (as compared to the commonly used medical necessity standard) in order to qualify for reimbursement. The federal guidance falls short of explaining what may qualify as “medically appropriate,” so it is unclear how a provider decides who gets a test that is paid for by an insurer. It is assumed those with symptoms will get provider-approved testing that the individual’s health insurance will cover. But what about the individual who has had a contact with someone diagnosed with COVID-19 – does that meet the standard of medically appropriate? Or should testing for this person be part of a state’s public health contact tracing and testing, which is outside the scope of health insurance coverage?
Federal law and subsequent guidance further require that these health insurers cover out-of-network testing provider claims at the provider’s publicly posted cost, which has been reported as high at $2,315 per test. While most providers charge between $50 to $200 and Medicare reimburses $100 for COVID-19 tests, state employee health plan (SEHP) administrators have reported extreme claims in excess of $1,000 for some of their members’ tests. Such high cost claims are unsustainable, particularly for SEHPs that are impacted by the states’ budget crises caused by the economic downturn, especially if individuals need multiple tests.
Although the federal guidance released June 23, 2020, did not provide health insurers with cost containment options for out-of-network testing claims, it does address testing in workplaces. Group health plans and individual insurance coverage are not required to reimburse testing costs for public health surveillance or employment purposes. The guidance notes that “testing conducted to screen for general workplace health and safety,” such as employee “return to work programs,” is beyond its scope of law’s requirement of health insurers. This will come as a relief to SEHPs that have received multiple testing claims for employees’ dependents who are required by their employers to get daily tests. However, it raises anew the question of who will pay for tests? Understanding it is outside the scope of health insurers, is it the direct responsibility of individual employers or can federal funds allocated to states for their public health efforts be used for employment testing? Complicating the issue further, the guidance does not address how often testing should occur for individuals returning to work or if there is a specifically recommended frequency of testing for particular jobs, raising issues for the health of individuals and financial responsibility of employers.
Without clear guidance on the level of testing needed, it is unclear if the existing Congressionally allocated funding is enough, even with the requirement that health insurers further subsidize testing. The lack of an evidence-based testing protocol could put the public’s health at risk and undermine state efforts to reopen their economies. While states have already made strides to establish comprehensive contact tracing, these efforts could be further enhanced by nationally coordinated testing efforts. And, without some federal guidelines on COVID-19 testing rates, reimbursements for extremely expensive provider tests could be a driver of health costs for some insurers.
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.
As states loosen restrictions on stay-at-home orders, many are struggling to establish clear and consistent COVID-19 testing protocols to support individuals’ safe return to work and school and identify ways to pay for increased testing. Absent federal guidance, there is significant debate about who is responsible for funding testing – insurers argue a test must be medically necessary and employers already hard hit by shutdowns contend that paying for testing is a public health obligation.
Multiple federal programs have recently emerged that fund testing, but to date, they primarily cover only the uninsured and there is no clear roadmap for how these fragmented funding streams interrelate and how states should respond. One small piece of the solution appears to rest in state Medicaid programs.
Under the Families First Coronavirus Response Act (FFCRA), states can enroll qualifying uninsured individuals in a new Medicaid eligibility category that covers diagnostic testing and testing-related services, as well as antibody tests. The option is available from March 18, 2020 (when the law was enacted) through the end of the public health emergency period, and states that have chosen this option receive a 100 percent funding match for the new group.
While there is no income limit for individuals to be eligible for the new Medicaid COVID-19 testing group, individuals must meet other qualifying criteria:
- Individuals must be uninsured – not enrolled in private market coverage or in other federal health programs such as Medicare or a mandatory Medicaid eligibility group, with the following stipulations:
- Individuals who are enrolled in short-term limited duration plans are considered to be uninsured for purposes of eligibility for this new group.
- Individuals who live in states that have not implemented the Affordable Care Act’s (ACA) Medicaid expansion but who would have been eligible for the ACA expansion group are eligible for coverage through the COVID-19 testing group if they have no other health coverage.
- Individuals who are enrolled in Medicaid coverage that offers a limited benefit package (e.g., coverage for tuberculosis, family planning-only services, or individuals who qualify as medically needy) are also eligible for the new Medicaid coverage option.
- Individuals must be state residents, provide proof of US citizenship or of a qualifying immigration status, and a Social Security number.
With limited federal guidance available initially – until recent guidance was issued earlier this month – states that chose to implement the option had to take the initiative in determining how to operationalize their enrollment processes for the new eligibility group. States have taken different implementation approaches, depending on the structure of their eligibility determination systems and procedures.
How States Are Implementing the New Medicaid Option
Connecticut opted to build off of its existing eligibility determination processes, and the state now conducts a full assessment of Medicaid eligibility of uninsured individuals seeking coverage for COVID-19 testing. Individuals apply through the state’s Access Health CT portal, which allows for a real-time eligibility determination. While using the complete eligibility determination process results in individuals who are potentially eligible for the COVID-19 testing group receiving notices indicating they are ineligible for Medicaid, the state has developed tailored messaging that informs these individuals that they will be assessed for eligibility for the COVID-19 testing group. State agency staff then use a manual process to evaluate whether these individuals qualify for the testing group. The state also looked back at applications filed since March 18 to identify other potentially eligible individuals and enroll them in the option. Despite requiring additional staff work, this manual part of the process has been fairly manageable because current enrollment is relatively low — about 600 individuals have been enrolled into the new group since the launch of the initiative in early May. In addition to information on the state’s website, state officials have actively publicized the option through provider bulletins, press releases, and outreach to a wide range of stakeholders.
In anticipation of a potential influx of applicants, New Mexico chose to assign the applications for the testing group to a separate unit of eligibility determination workers to prevent regular Medicaid application offices from becoming overburdened. The state created a simplified application for individuals applying for the COVID-19 testing group, and has also developed a memo outlining how providers can bill Medicaid for eligible individuals. To help expedite the establishment of the program, the state chose to use an existing eligibility category code that was already programmed into the state’s system. During the current initial implementation phase, most of the applications have been paper-based. State officials are in the process of developing a mobile-enabled online application to allow individuals to fill out the form on their phones when they are waiting in their cars at testing sites.
In Utah, state officials report they are developing a hybrid eligibility determination process for the new group that will allow for both paper-based and online applications. When the coverage option launched on June 1, 2020, the state began accepting applications through its presumptive eligibility portal tool, which allows for a simplified and streamlined process and a full Medicaid eligibility determination. Individuals will also soon have the option to use a simplified paper application to apply, and the state also identifies potentially eligible individuals from its general pool of denied Medicaid applications. Utah officials are in the process of working with testing sites to enable automatic loading of multiple applications simultaneously into the state’s system. Also, like New Mexico, the state is developing ways for individuals to easily apply for coverage in real time when they are at testing locations.
Multiple, Uncoordinated Sources of Federal Funds Support Testing for Uninsured
A complicating factor for states deciding whether to implement the new Medicaid coverage group is that there are other pools of federal funding for COVID-19 testing, but it is unclear how they are all intended to interact. The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program reimburses providers for COVID-19 testing and treatment claims for uninsured individuals starting on Feb. 4, 2020. Specifically, the program’s FFCRA relief fund contains $2 billion for provider reimbursement for COVID-19 testing of uninsured individuals. Providers are able to submit claims through a portal managed by the Health Resources and Services Administration (HRSA) in order to receive reimbursement equal to Medicare rates. Unlike the Medicaid option, proof of citizenship or a qualifying immigration status is not required. Additionally, the Paycheck Protection Program and Health Care Enhancement Act also established a $25 billion COVID-19 testing fund, of which $1 billion must be used to cover COVID-19 testing for uninsured individuals (this $1 billion was added to the FFCRA Relief Fund, bringing the total of that fund to $2 billion).
Some states have opted not to implement the Medicaid COVID-19 testing group — including Washington State, which already has an approved state plan amendment to do so — because of the availability of reimbursement through the HRSA-administered fund, as well as anticipated operational challenges involved with implementing the Medicaid option. Some of these issues are related to potentially needing to make complex systems changes or complications with the application process, such as obtaining third-party signatures or conducting manual entry of applicants’ data. Another barrier is the potential additional burden on eligibility determination workers overall, who already may be managing a greater number of applications in states where Medicaid enrollment is beginning to increase.
Another consideration for states deciding whether to take up the Medicaid coverage option is that it is unclear how long the HRSA-administered funding will last. This concern about the finite funding through the HRSA portal is cited on Utah’s state webpage as one of the key reasons the state chose to implement the Medicaid testing eligibility group. Other states, such as Connecticut, began efforts to implement the Medicaid coverage option prior to the availability of the HRSA funds. In New Mexico, officials indicated they are not prescriptive in instructing providers how to submit claims for COVID-19 testing and recognize that providers may choose to utilize the HRSA reimbursement process instead of the Medicaid coverage option, particularly because some of the HRSA funding also covers the cost of COVID-19 treatment.
Currently, some states that have implemented the new Medicaid eligibility group are weighing whether to invest more resources to automate enrollment processes for these applicants, but may be hesitant to do so because the coverage category is temporary. While this new Medicaid eligibility group will no longer exist after the end of the public health emergency period, the need for COVID-19 testing of uninsured individuals will remain a pressing issue for the foreseeable future. State officials continue to emphasize the need for greater federal-level recognition and support of states’ testing needs, including testing of asymptomatic individuals, beyond the emergency period and across all health coverage programs.
|Key Federal Funding Sources for COVID-19 Testing and Treatment
|Families First Coronavirus Response Act (FFCRA)
|New optional Medicaid eligibility group provides coverage of COVID-19 testing for uninsured individuals||States receive 100% federal medical assistance percentage (FMAP) for testing and testing-related services for enrolled individuals and related administrative costs|
|FFCRA Relief Fund||$1 billion to reimburse providers for testing and testing-related services for uninsured individuals|
|Coronavirus Aid, Relief, and Economic Security (CARES) Act
|Provider Relief Fund||$100 billion, primarily to compensate providers for lost patient revenue, but an unspecified amount of the fund is available to reimburse providers for COVID-19 treatment|
|Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA)
|Additional funding for Provider Relief Fund||$75 billion in additional funding, bringing Provider Relief Fund to $175 billion|
|Funding for COVID-19 testing||$25 billion – $11 billion for state, local, and tribal governments and $1 billion added to FFCRA Relief Fund to cover testing for uninsured individuals|
As recent data shows, COVID-19’s infection and death rates illustrate the profound racial and ethnic disparities in the nation’s health care system and the social and economic inequalities that affect health outcomes. To curb COVID-19 and improve the quality of care delivered to communities that have faced decades of discrimination, a few states are bolstering their community health workforces.
Community health workers (CHWs), are culturally competent, frontline public health workers who are trusted by the communities they serve. Evidence suggests individuals benefit from relationships with people who have similar lived experiences and are members of their community. CHWs are uniquely positioned to build trust and address barriers that traditionally underserved communities face when seeking medical care and services. CHWs can also provide collaborative, patient-centered approaches to care and generate cost savings for state programs.
History of State CHW Initiatives
Before the pandemic, many state programs enlisted CHWs to address challenging aspects of their health improvement initiatives, such as facilitating care coordination, enhancing access to community-based services, and addressing social determinants of health. Payment strategies for CHWs vary; a majority of services are grant-funded with some states reimbursing for CHW services through their Medicaid programs or hiring CHWs as part of managed care organizations.
As states work to address COVID-19, they are bolstering their health care workforces, ramping up contact tracing programs, and finding new ways to fill the gaps in the public health infrastructure created by chronic underfunding. With increased recognition of the adverse health impacts of structural racism, CHWs — who were deemed essential critical infrastructure workers” by the Department of Homeland Security — may strengthen the emergency response and facilitate recovery across demographics.
State Examples of CHW Engagement to Address COVID-19
- Delaware: In May, Gov. John Carney announced a partnership with Healthy Communities Delaware — a collaboration between the Delaware Division of Public Health, the Delaware Community Foundation, and the University of Delaware. The partnership’s goal is to provide linkages between those who test positive for COVID-19 and CHWs, who can help coordinate basic needs like grocery delivery and housing during a period of quarantine. Healthy Communities Delaware is coordinating the effort in partnership with community-based organizations.
- Hawaii: The University of Hawaii is partnering with the Hawaii Department of Health to expand the CHW curriculum at community colleges so that graduating CHWs are equipped to assist with COVID-19 contact tracing efforts. CHWs will specifically help with contact tracing efforts in Native Hawaiian/Pacific Islander communities, which are disproportionately affected by COVID-19, and among individuals facing homelessness and unemployment.. The funding for this initiative was appropriated from Hawaii’s federal CARES Act relief funds.
- Massachusetts: The Office of Community Health Workers recently issued guidance for CHW employers detailing how they can engage CHWs in the state’s COVID-19 pandemic response. The suggestions include cultural competence training and outreach about the virus and its impacts, connecting individuals with community services and supports, and assisting people with the new technologies needed for telehealth appointments. The guidance also acknowledges the increased need for resources, technology, and employer support as CHWs take on a growing and varied number of challenges presented by the pandemic.
Some cities also present promising examples of how CHWs can factor into response and recovery plans. The City of Baltimore is responding to COVID-19’s dual economic and public health crises by creating the Baltimore Health Corps. The pilot program, funded by the CARES Act, the Baltimore City Health Department, the Mayor’s Office of Employment Development, and The Rockefeller Foundation, will hire and train individuals who have recently lost their jobs due to the pandemic to be contact tracers and CHWs. The Health Corps will primarily serve communities that have been disproportionately impacted by COVID-19.
The examples above spotlight how partnerships between different sectors allow cities and states to address the needs of specific populations, to create jobs, and to ramp up their contact tracing workforces. Each addresses the need for equitable care that is delivered by people who understand the lives and challenges of the community they are serving in order to make sure interventions are appropriate and effective. States may want to consider adopting similar strategies along with training their existing CHW workforces for the new challenges of COVID-19 response and recovery.
The brutal deaths of Breonna Taylor, Ahmaud Arbery, George Floyd, and countless people of color before them, and the shocking disparities in death rates from the coronavirus, are tragic examples of the still pervasive racism in America. For organizations like NASHP, it is not enough to speak out – we need to redouble our efforts, along with our state partners, to combat racism and ensure health equity. NASHP pledges to more intently listen to Black voices, to work harder to frame policies rooted in the experiences of communities that have been disenfranchised for far too long and, most importantly, to make way for, seek out, and support Black leadership in state health policy. We won’t achieve the change we need until we first change ourselves.
Health Equity Resources
COVID-19 and Health Equity
American Medical Association: Why African American Communities Are Being Hit Hard by COVID-19, May 13, 2020. Join a virtual town hall hosted by the AMA and the National Association of Black Journalists exploring COVID-19 and the black community, moderated by NABJ President Dorothy Tucker, an investigative reporter for CBS 2 Chicago (WBBM-TV).
Journal of the American Medical Association: COVID-19 and Health Equity — A New Kind of “Herd Immunity,” May 11, 2020. Segregation of health care also contributes to racial disparities in health care. COVID-19 testing centers are more likely to be in well-off suburbs of predominantly white residents than in low-income neighborhoods that are predominantly Black. The advice to obtain testing through a primary care clinician limits access to testing for people who lack one. Improving access to care for all and ensuring high-quality care, with greater focus on under-resourced settings and vulnerable groups, is an important “treatment” for racial disparities in health.
American Medical Association FAQs: Health Equity in a Pandemic, April 2020. Marginalized and minoritized patients have and will suffer disproportionally during the COVID-19 crisis. The AMA is answering frequently asked questions on health equity in the pandemic response to equip physicians with the consciousness, tools and resources to confront inequities.
American Medical Association You Tube Health Equity Discussion: Physicians Detail COVID-19’s Impact in Latinx Communities, May 21 2020. More than 28 percent of people diagnosed with COVID-19 are Latinx. Aletha Maybank, MD, MPH, chief health equity officer and group vice president of the AMA, joins four Latinx physicians to discuss how the coronavirus has impacted their communities.
Police Violence Impact on Community Health
UNC Center for Health Equity Research: Health Equity Implications of Police Violence, August 2017. As of August 2017, the US is on track to approach 1,000 deaths of civilians at the hands of police for at least the third year in a row. This brief provides an overview of existing evidence documenting police-related killings of civilians, and suggests key strategies to mitigate the disparate health impacts resultant from those acts of violence.
The Lancet: Police Killings and their Spillover Effects on the Mental Health of Black Americans: A Population-Based, Quasi-Experimental Study, July 28, 2018. Police kill more than 300 Black Americans — at least a quarter of them unarmed — each year in the United States. These events might have spillover effects on the mental health of people not directly affected.
American Psychological Association PsycNet: Black and Blue: Exploring Racial Bias and Law Enforcement in the Killings of Unarmed Black Male Civilians, April 2016. The report attempts to disentangle racial bias from common characteristics of law enforcement agents (e.g., social dominance orientation), while also addressing the interaction between racial bias and policing to more effectively identify and develop solutions to eradicate excessive use of force during interactions between “Black” (unarmed Black male civilians) and “Blue” (law enforcement).
American Journal of Public Health: Unequal Burdens of Loss: Examining the Frequency and Timing of Homicide Deaths Experienced by Young Black Men Across the Life Course, July 2015. A study of the frequency and developmental timing of traumatic loss resulting from the health disparity of homicide among young black men in Baltimore.
Contact tracing, a strategy long-used to contain the spread of infectious diseases by identifying and isolating people exposed to an infection, has become a crucial state tool to curb COVID-19. But the pandemic requires significant ramping up of contact tracing capacity and funding. Experts estimate 30 contact tracers are needed for every 100,000 Americans – a total of 98,460 workers nationwide – far short of states’ current tracer workforces.