As states rapidly work to get COVID-19 vaccines into arms as quickly as possible as viral variants spread, state officials know vaccine rollout plans must focus on equitable distribution to communities of color, especially Black and Latinx communities that have experienced disproportionately high infection rates, hospitalizations, and deaths. However, early data suggests that these populations are receiving vaccines at lower rates than White Americans.
Pharmacies will be a critical venues for vaccine access, and this pharmacy distribution program is expected to build that capacity as the US Centers for Disease Control and Prevention (CDC) and state health directors work together to identity areas of need and ship vaccines to pharmacies in those areas, especially in the early days of the program when distribution is still curtailed by limited vaccine supplies. State officials told NASHP that the selection of pharmacies will be based on their ability to both reach the most vulnerable populations and also align with states’ current distribution phases and priority populations in their vaccination plans.
Tracking and Reporting Race and Ethnicity Data
One of the first steps to ensure equitable access to vaccines is having the data to determine where disparities exist. Forty-eight states and Washington, DC currently collect and share varying levels of vaccine data in publicly available data dashboards. Of these, 26 states and Washington, DC publicly display race and ethnicity data for individuals who have received their vaccines. States report the data slightly differently – which can result in different conclusions about their efforts. They are reporting either:
- Total number of individuals vaccinated by race and ethnicity (for example, Florida and Pennsylvania);
- Percentage of total individuals of each race or ethnicity in the state who have been vaccinated (North Dakota); or
- Percent of total doses that have gone to individuals by each race and ethnicity (Indiana and North Carolina).
While these state trackers provide some insight into who is getting vaccinated, there are limitations in their data – a large percentage of race and ethnicity data is either missing or not reported. Nationwide, race and ethnicity data is missing for nearly half of those vaccinated, compared to age and gender data, which is reported 99.9 and 97 percent of the time, respectively. Even in states that collect and publicly report this data, some report over 50 percent of doses with “unknown” race and ethnicity. Providers will report “unknown” in the race and ethnicity fields either because the providers do not ask for the data, or because the recipients do not provide it. It is unclear why individuals are declining to provide their race and ethnicity, but some experts believe that some concerns may stem from a fear that their demographic data could be misused. For example, immigrants are concerned that getting the vaccine – or providing their data – may negatively affect their immigration status. However, the CDC said that vaccine data cannot be used for immigration enforcement, and that getting the COVID-19 vaccine will not be considered as part of the public charge inadmissibility rule.
Many states are working to improve their data collection and reporting. Some, such as Alabama, are collecting race and ethnicity data but have not yet made it public because it is incomplete. These states are working to collect complete and accurate data before publishing it. Most states that are reporting race and ethnicity data publicly do not require providers to include that information, citing a lack of express permission from the patient or concern that requirements might prevent providers from reporting vaccine doses at all.
Other states are imposing requirements to improve data. In North Carolina, Department of Health and Human Services Secretary Mandy Cohen pushed to make race and ethnicity a required field in the state’s COVID-19 vaccine registry. According to state officials, North Carolina emphasizes equity as a core value and conducts outreach and training with providers to emphasize the importance of race and ethnicity data. The availability of the data has enabled outreach strategies, such as partnerships with faith leaders.
While requiring providers to upload race and ethnicity data can add to administrative and logistical challenges, collecting the data is critical to ensuring that vaccine outreach and administration are targeted to the communities most in need. If large percentages of race and ethnicity data are missing, ensuring equity in distribution becomes much more difficult.
Locating Clinics in High-Need Areas
Delivering vaccines to underserved communities is key and the new Federal Pharmacy Program helps address this goal. States and local health departments can use preliminary data to identify counties or jurisdictions with disparities and low rates of vaccination uptake to use to target their vaccination efforts.
Rick Palacio, the cochair of Colorado’s COVID-19 Vaccine Equity Taskforce, announced that one of the state’s goals is to hold pop-up vaccination clinics in half of the state’s top 50 census tracts containing low-density, low-income communities. Officials emphasized the importance of using data to determine under-vaccinated areas and tailor communication strategies to reach those residents. The state kicked off this plan by vaccinating more than 10,000 seniors at a mass vaccination event in Denver and plans to expand the initiative as it receives more doses.
Other examples of state efforts to identify and reach underserved areas include:
- Rhode Island is using its hospitalization, death, and case data to target vaccine distribution by geography. Vaccines will be available in community clinics, pharmacies, and housing sites in communities that have been identified as high risk.
- Illinois has had success by holding events scheduled by local health departments that reached out to discreet, hard-to-reach communities and invited them to register for a vaccine appointments.
- Connecticut is closely tracking vaccine rollout in localities that rank high on the social vulnerability index.
- After Washington, DC opened its vaccine registration portal to all individuals over the age of 65, data quickly showed that an outsized proportion of appointments was going to wealthier White residents. In response, health officials made more appointments available for residents in parts of the city that were currently securing the fewest vaccine appointments. The city also started making appointments for residents in these high-priority zip codes available a day before other eligible residents could register.
- North Carolina has partnered with faith leaders to ensure communities of color and underserved communities have access to vaccinations at the state’s mass vaccination clinics, including releasing appointments to Black and Latinx church attendees before opening up registration to the general public.
States can also reduce transportation barriers to increase vaccination uptake and ensure transportation will not be a barrier for targeted populations to access the vaccine. North Carolina’s mass vaccination clinic location was chosen for its proximity to public transportation.
The Tennessee Department of Health (TDH) is expanding access to the COVID-19 vaccine by focusing on increasing vaccinations in rural and underserved areas. TDH partnered with pharmacies and community health clinics to add over 100 vaccination sites across the state, focusing on “hard-to-reach” areas, as identified in the state’s vaccination plan. Tennessee’s state plan indicated that 5 percent of the state’s allocation of COVID-19 vaccines are earmarked for use in targeted areas with vulnerable populations.
Additionally, at a February US House Energy and Commerce Oversight and Investigations Subcommittee hearing, Louisiana state officials cited a plan to create community mobile strike teams that will travel to areas that rank high on the social vulnerability index to administer vaccines. The strike teams will be staffed by the National Guard and funded by the Federal Emergency Management Administration, which reimburses states for 100 percent of costs associated with the National Guard’s COVID-19 relief efforts. A state official in Michigan also noted at this hearing that the increase in doses from the federal government will help advance equity, because those extra doses can be distributed directly to underserved areas and minority populations.
Tailoring Communication Strategies to Address Vaccine Hesitancy
While reporting and tracking vaccination data and removing logistical barriers are important strategies for identifying pockets of need, they alone are not sufficient to reduce disparities. A history of racism in the health care system has led to distrust by communities of color. Though the share of adults planning to get the COVID-19 vaccine has increased over the year, according to recent surveys White adults (53 percent) remain more likely than Black (35 percent) and Latinx (42 percent) individuals to want to be vaccinated as soon as possible. A survey last fall found that less than 20 percent of Black Americans trusted vaccine safety and efficacy. The survey also indicated that the best messengers to support vaccination in these communities are those living in their own communities, or their health care providers.
State officials and several members of the federal Advisory Committee on Immunization Practices (ACIP) mentioned that the desire to vaccinate quickly must be balanced with the need to reach vulnerable communities. State officials note that balancing speed and equity is one of the biggest challenges they face. Community input builds trust and assists in building effective and acceptable strategies. For example, Tennessee has an African American Health Care Clinician Workgroup, with working members from the NAACP, the Black Nursing Society, and other Black organizations, who are disseminating messaging on the importance of vaccinations and will ultimately help vaccinate Black communities. The Colorado Department of Health and Environment has released commercials in English and Spanish featuring Colorado health care workers who are people of color, promoting the message that vaccines are safe. West Virginia is funding faith-based community members and people of color to administer COVID-19 vaccines directly to communities of color, ascribing to the principle that having trusted, local figures helping with distribution will improve those communities’ confidence in the vaccine.
Federal and state governments are working to vaccinate residents as quickly as possible, while also working to ensure doses are equitably distributed. In light of reports of disparities in vaccination rates and in vaccination access among people of color and in rural communities, the Biden Administration is acting on its promise to ensure an equitable distribution, including their new strategy to ship extra doses to pharmacies in hard to reach areas. While distribution strategies vary across states and are continually tweaked to improve efficacy and equity, the emerging best practices:
- Use data to track and identify under-vaccinated areas and populations;
- Set up additional clinics in underserved areas and provide additional doses to these clinics;
- Ensure transportation is available for patients to access the clinics; and
- Partner with local agencies and community organizations to promote vaccine confidence.
Each of these components is necessary to ensure underserved communities and communities of color are interested in receiving vaccines and are able to access them.
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.
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.
With elections just three weeks away, governors’ races in 36 states – with 17 open seats – are down to the wire and important health policy issues, such as Medicaid expansion, stabilizing insurance markets, public options, and prescription drug price controls, are at play in most of them. The National Academy for State Health Policy (NASHP) scanned candidates’ websites and press coverage to provide this snapshot of key health care election issues. While limited in scope and focusing only on major party candidates, this scan provides a glimpse of state campaign health issues that could be harbingers of policy action in 2019.
Addressing the opioid epidemic: No surprise to state health policy watchers, addressing the opioid epidemic remains a bipartisan priority for gubernatorial candidates. Strategies differ, but there is general support for more treatment and prevention. In Iowa, Democrat Fred Hubbell wants more support for local law enforcement and has called for the attorney general to hold pharmaceutical manufacturers accountable. In Oregon, Republican Knute Buehler seeks to cut opioid overdose deaths by 50 percent by investing in medication assisted treatment (MAT), peer counseling, and evidence-based strategies to address the crisis while incumbent Democrat Kate Brown cites her creation of a task force that is tackling these issues and her leadership to increase the availability of naloxone. In several states that have not expanded Medicaid, Democratic candidates are supporting expansion as a means to improve addiction treatment coverage.
Medicaid expansion: Seventeen states have not expanded Medicaid and that issue is front and center in many of these races. Candidates’ stances on the issue follow party lines, with Republican candidates opposing expansion and Democrats supporting it. A number of these states have open seats and highly competitive races. Whether pollsters have it right or not, these state campaigns provide insight into the current debate about Medicaid expansion.
In states with both highly competitive races and open seats, arguments for and against expansion follow similar themes. In Georgia, Republican Brian Kemp argues that the state can provide affordable health care without expanding Medicaid while Democrat Stacey Abrams has made expansion a top priority, noting its importance for coverage, mental health treatment, jobs, and support for rural hospitals. In Kansas, a recent plan to close a rural hospital is cited as one of the reasons to support expansion by Democrat Laura Kelly while Republican Kris Kobach opposes expansion. Oklahoma’s Democrat Drew Edmondson expresses strong support for expansion and he too cites the issue of rural hospitals’ financial challenges while Republican Kevin Stitt does not mention expansion on his website but seeks an audit of Medicaid spending. In Florida, Republican Ron DeSantis does not mention Medicaid on his website, but has stated opposition to expansion, while Democrat Andrew Gillum supports expansion. Democrats in South Dakota and Tennessee also support expansion and cite the plight of rural hospitals as a key factor.
In Idaho, Nebraska, and Utah, Medicaid expansion is on the ballot. In Maine, a successful citizen initiative in 2017 was stymied by outgoing Republican Gov. Paul LePage’s resistance, because the state legislature had not appropriated funds that met his conditions. After numerous court battles, LePage submitted a state plan amendment to expand Medicaid to the federal government, but urged them to deny it. In the state’s current gubernatorial race, Republican Shawn Moody mirrors LePage’s opposition while Democrat Janet Mills has made expansion a top campaign priority. In Idaho, Republican Brad Little says he will enforce expansion if that state’s ballot initiative passes, but he raises concerns about “uncertainty at the federal level.” In Nebraska, Republican incumbent Pete Ricketts strongly opposes expansion but concedes the issue is up to voters.
Medicaid work requirements: Support for work requirements generally follows party lines, but in Alabama Democrat Walt Maddox supports work requirements as part of his endorsement of Medicaid expansion. In Ohio, Republican Mike DeWine supports a “reasonable work requirement” for individuals newly covered by Medicaid expansion who are healthy and able to work.
Improving affordability of private coverage: Candidates have proposed a wide array of approaches to make health insurance coverage in the individual and small group markets more affordable.
In about one-third of the states, candidates are talking about a public option, the opportunity to buy-in to Medicaid, or other initiatives. In Alaska, Democrat Mark Begich wants to combine coverage for individuals on Medicaid, Medicare, TriHealth, and Indian Health Services into a single health care option. In Connecticut, Democrat Ned Lamont proposes strengthening the Access Health CT exchange by instituting a Medicaid buy-in option to lower costs by adding younger participants to the pool. In Illinois, Democrat J.B. Pritzker is proposing a public option/Medicaid buy-in — Illinois Cares — to allow every resident to buy low-cost health insurance. Pritzker wants to work with legislators and the health care community to design this public option as another choice on the health insurance marketplace. Minnesota’s Tim Walz, a Democrat, wants to provide a strong public health care option and suggests that MinnesotaCare, the state’s Basic Health Program, can already serve that role. In New Mexico, Democratic candidate Michelle Lujan Grisham supports “cost-effective, innovative approaches to providing affordable, high-quality health care to all New Mexicans,” including a Medicaid buy-in. Maine’s Democratic candidate Janet Mills proposes the Small Business Access Plan, a buy-in to public purchasers for small businesses and self-employed individuals.
Republican candidates, however, generally warn against a “government takeover” of health care and express concern about the high costs to taxpayers of such proposals.
A few Democrats express support for Medicare for All proposals and some identify incremental steps a state could take toward that goal. In Arizona, Democrat David Garcia supports a Medicaid buy-in as a strategy while Colorado Democrat Jared Polis seeks to “pioneer a western single-payer system” by partnering with other western states to develop a regional, multistate consortium to provide a common payer system to reduce prices, increase coverage, and improve care quality.
Premium rating rules: In Colorado, Republican Walker Stapleton said he would convene a task force to evaluate the state’s Affordable Care Act (ACA) rating regions, geographic boundaries, and departmental overlap. He opposes a single rating region supported by Democratic candidate Jared Polis, who is advocating a statewide geographic rating system and reconfiguration of rating zones with rural rate protections.
Reinsurance: In Georgia, both candidates support creating a reinsurance program to stabilize rates in the individual insurance market. Reinsurance is also supported by Democratic candidates in Colorado and Connecticut. Wisconsin Gov. Scott Walker lauds his state’s reinsurance program, Health Care Stability Plan, and notes the state is investing $200 million in market-based solutions to lower costs, which he predicts will reduce rates by 3.5 percent in 2019.
Market-based strategies: Many candidates support market-based solutions, including Colorado Republican Walker Stapleton, who would address rising health care costs for families by creating more insurance choices for consumers, such as association health plans (AHPs), short-term plans, and catastrophic coverage options. This approach is similar to strategies offered by Georgia’s Republican candidate Brian Kemp who would set “specific, achievable goals to lower the uninsured population by expanding choices” and indicates he would embrace AHPs if elected. Minnesota Republican Jeff Johnson believes MNsure has been a “complete disaster” and that new approaches are needed. He notes the “skyrocketing” cost of health insurance and lack of access to care and has proposed to request waivers to “abandon the provisions of Obamacare” because they limit choice and increase costs. He supports an interstate compact to buy and sell health insurance across state lines. Oklahoma’s Kevin Stitt similarly supports buying coverage across state lines.
A few candidates are focusing on retooling primary care. Florida Republican Ron DeSantis said he would back proposals to install direct primary care models, in which patients pay a monthly rate directly to doctors to cut out insurers. Kansas Republican Kris Kobach supports allowing patients to pay their doctors $50 a month for unlimited primary care visits.
Several candidates offer different approaches. In New Mexico, Republican Steve Pearce would encourage employers to provide health insurance by providing a tax credit for employees who work less than 20 hours per week. In New York, Republican Marc Molinaro suggests addressing high taxes on private health insurers to increase health care quality and affordability. In Rhode Island, Gov. Gina Raimondo recently issued an executive order directing the state to codify all ACA protections into state law. Her Republican opponent, Allan Fung, wants to keep the state-based exchange and control of insurance regulation in-state, and does not want to change the existing protections “whether it’s pre-existing conditions” or “taking away coverage” or changes in Medicaid eligibility. Maryland Gov. Larry Hogan opposes any changes to the ACA that would “jeopardize Marylanders’ access to quality health care” and supports stabilizing the insurance market and keeping premiums down. In contrast, South Carolina Gov. Henry McMaster states that “Obamacare was an unprecedented encroachment on state sovereignty” and wants to ensure greater access and affordability through removal of anti-free market mandates and regulations to allow for investment, expansion, and ingenuity to lower health care costs. Maine’s Democratic candidate Janet Mills would protect against rollbacks of ACA protections and also supports “well-regulated” AHPs.
Reducing prescription drug costs: Addressing rising pharmaceutical costs is another issue that has bipartisan support. A number of candidates from both parties indicated support to lower costs on their websites while others present specific proposals.
In Ohio, Republican Mike DeWine advocates for greater transparency of drug prices by bringing more attention on pharmacy “middle men.” His Democratic opponent, Richard Cordray, has also supported more transparency around pharmacy benefit manager (PBM) activities. In Colorado, Democrat Jared Polis seeks to improve support for the state’s all-payer claims database (APCD) and to use data to identify health care savings. He also advocates for increased transparency by requiring drug companies to publicly disclose pricing and would crack down on price gouging by forcing drug companies to justify price increases. Additionally, he proposes to set up a framework to import prescription drugs from Canada. Other Democratic candidates also support importation, including Drew Edmonson of Oklahoma, Tony Evers of Wisconsin, as well as Ben Jealous of Maryland, who supports a Prescription Drug Affordability Plan that requires drug companies to give notice when increasing prices and drug spending caps for Medicaid. Connecticut Democrat Ned Lamont wants to “take strong and multipronged action to reduce drug prices” and supports pricing transparency for manufacturers, including requirements that drug companies include their wholesale prices in advertisements. He also wants to limit coupon use in private insurance and cap out-of-pocket pharmaceutical costs. In contrast, his Republican opponent, Brad Stefanowski, opposes government regulation of prescription drug costs.
Two candidates propose expanding the state’s public purchasing role to lower costs. Nevada Democrat Steve Sisolak proposes creating Silver State Scripts — a consortium of private and public health plans that will negotiate for lower drugs prices, while New Mexico Democrat Michelle Lujan Grisham seeks to pool state resources to reduce drug prices.
In Maine, Republican Shawn Moody proposes to lower prescription drug costs by providing greater access to generic drug alternatives. Democrat Janet Mills has a multifaceted plan to lower drug prices that includes investigating pooling public purchasers, increasing transparency and following the work in other states on importation and establishing payment caps to “step in quickly if solutions pioneered elsewhere take hold”. In Wisconsin, Gov. Scott Walker wants to make permanent a waiver for SeniorCare, a program to make prescription drugs more affordable for seniors, while Democrat Tony Evers proposes a rate review board and banning PBM gag clauses. In Oregon, Republican Knute Buehler has made drug pricing a major campaign issue. He wants to prosecute leaders of price-gouging pharmaceutical companies and would like to adopt a single formulary for all state taxpayer-funded drug purchasing. Incumbent Kate Brown cites her work in the past to support price transparency.
Social determinants of health: A number of candidates have targeted social determinants of health, including Arkansas Democrat Jared Henderson who proposes reducing teenage pregnancy and childhood poverty as ways to address long-term health care spending without reducing Medicaid enrollment. In Ohio, Republican Mike DeWine has a plan for wellness programs that would require Medicaid managed care plans to provide education and promote healthy benchmarks geared towards upstream prevention efforts. Colorado Democrat Jared Polis suggests moving toward global budgeting for hospitals, which would provide them with a set amount of revenue that could incentivize efficiency, innovation, and a focus on social determinants of health and preventive care. Oregon Republican Knute Buehler wants to coordinate investments, set financial expectations, and determine specific metrics in social determinants of health, such as workforce training, employment, community engagement, and housing. Democrat Karl Dean of Tennessee supports preventive health care and promoting healthy lifestyles, and as governor would focus on preventing childhood obesity because of its link to both chronic health problems later in life as well as social and emotional issues.
Delivery system and payment reforms: States have been actively engaged in a variety of reforms designed to improve how care is delivered and paid for –moving from a volume- to a value-based system – and a number of candidates have embraced these efforts. In Colorado, both candidates refer to the lessons learned from the state’s State Innovation Model (SIM) initiative. Democrat Jared Polis wants to use lessons from SIM to increase access to integrated physical and behavioral health care and supports moving Colorado Medicaid to a bundled payment system. He also proposes global budgeting for hospitals and using health information technology to measure hospital care quality and tie payments to community health improvement. Republican Walker Stapleton wants to build on the success of the state’s SIM work and continue expanding the state’s Regional Accountability Entities to make sure reimbursement systems promote the best patient outcomes. Ohio Democrat Richard Cordray plans to reform the Medicaid payment system to incentivize primary and preventive care in physical and behavioral health, and would invest in high-quality, value-based programs. Oregon Republican Knute Buehler wants to prepare for a third generation of Coordinated Care Organizations (CCOs) by aligning early learning hubs, regional solutions, and related social and health services. He also proposes to reorganize Medicaid mental health services payment and delivery to fully integrate mental and physical health through CCOs (with counties continuing to serve as providers) and tie CCO funding to outcomes. Tennessee Democrat Karl Dean would continue the state’s work to promote health care value over volume, which has included phased implementation of episodes of care for TennCare enrollees.
This snapshot suggests governors’ races are fueling spirited discussions about health policy and promises a lively 2019 as policymakers continue to address how to provide affordable, high-quality health care and improve population health. New governors’ ideas will be considered by state legislatures, whose political make-up will also likely change, as 80 percent of all state lawmakers are up for election in November. As voters make their choices, NASHP will continue to track and support policymakers who advance solutions to the current challenges of health care access, cost, and quality, and help identify new opportunities for state innovation.
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.
|Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students.|
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.