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June 29, 2023 | Volume 27, No. 5| Archives

More on Murder #2

In This Issue: 
  • FY2024 Budget—and the Struggle Ahead
  • Medicaid Redeterminations: 1.5 Million People Now Disenrolled
  • A Closer Look: More on Murder #2/Deaths by Policy: Maternal Mortality
  • One Year Post-Roe v. Wade
  • Substance Use Issues in the News
  • Partner Resource Highlight: NLIHC 2023 Out of Reach Report
  • COVID Corner
  • Climate Change and Homelessness
  • What We’re Reading
FY2024 Budget — and the Struggle Ahead
    Now that the debt ceiling issue has been (temporarily) addressed, the House and Senate Appropriations Committees are drafting the annual appropriation bills that will set discretionary spending levels for Fiscal Year (FY) 2024. Unfortunately, a group of conservative House Republicans—angry that the debt ceiling agreement did not cut enough funding from the budget—are continuing to pursue drastic reductions to the federal budget. Their goal continues to focus on reducing the budget to FY22 levels, which would mean taking another $115 billion away from discretionary programs. This would be especially devastating to housing assistance programs, which would see a 25% cut, as well as food assistance programs.
    The Senate has not indicated interest in such deep cuts, which sets up a significant conflict between the House and the Senate over the budget. With only 100 days left in the fiscal year (with recess for July 4th holiday and much of August) and political factions digging in, insiders on Capitol Hill are talking about the potential for a government shut-down. Stay tuned for more information. 

    Take Action on the Budget: 

    • Call your representatives in the House and tell them to support desperately needed increases in the budget, not drastic cuts to life-saving services.
    • Illustrate how cuts to health care, housing, and other services would impact you, your program, and your community.
    alert sign
    Medicaid Redeterminations: 1.5 Million People Now Disenrolled
    Everyone knew this was coming, and now here we are: as of June 22, over 1.5 million people across 25 states (plus DC) have been disenrolled from Medicaid because of the post-COVID unwinding—according to the Kaiser Family Foundation’s Medicaid Enrollment and Unwinding Tracker. Nearly 80% of disenrollments were terminated for administrative reasons (meaning: a technicality like paperwork not being returned), not because they’ve actually been deemed ineligible. No doubt, there’s more losses coming since 10 states have yet to start their redeterminations process. Arkansas is a prime example of a state taking a sledgehammer to Medicaid at breakneck speed as they’ve kicked 140,000 people off the rolls since April (82% for administrative reasons).
    To try and stem the losses, HHS is circulating a list of 23 strategies that states can use to mitigate against coverage losses and HHS Secretary Becerra sent a letter to states urging them to adopt as many of these strategies as possible. Five of these strategies may be especially helpful to the HCH Community:
    • Strategy #1: Use SNAP and TANF data to redetermine income-based eligibility
    • Strategy #3: Renew Medicaid eligibility for individuals with zero income and no data returned
    • Strategy #4: Renew Medicaid eligibility for individuals with income at or below 100% FPL and no data returned
    • Strategy #11: Renew eligibility if able to do so based on available information, and establish a new eligibility period whenever contact is made with hard-to-reach populations
    • Strategy #19: Designate providers as qualified entities to make determinations of presumptive eligibility on an income basis for individuals disenrolled from Medicaid or CHIP for a procedural reason in the prior 90 days

    Take Action on Medicaid Redetermination: 

    • Use our issue brief on Medicaid Redeterminations to find specific strategies health centers can take to improve internal processes.
    • Advocate to your state Medicaid agency adopt the new HHS strategies listed above (as well as those listed in our issue brief).
    • Raise awareness among patients/clients to ensure they know redeterminations happening (many people don’t know!).
    • Raise attention to this issue in the media and be sure to indicate how coverage losses are impacting the health and well-being of those newly disenrolled.
    silhouette of pregnant person
    A Closer Look: More on Murder #2/Deaths by Policy — Maternal Mortality
    By Barbara DiPietro, PhD, Senior Director of Policy
    Last month, I reflected on the death of Jordan Neely in New York City and how our society kills people three different ways: through direct physical violence (Murder #1), through indirect policy violence (Murder #2), and through silent ascent violence (Murder #3).
    This month, I’m struck by the death of Tori Bowie, an Olympic athlete who died in childbirth in Orange County, Florida. Like Jordan Neely, Tori is Black, but unlike Jordan, she was not homeless—she had housing, resources, and strong support systems. Yet still she died.  As it turns out, this isn’t uncommon in the United States, especially for Black women.
    THE DATA: The maternal mortality rate* in the U.S. is nearly three times higher than in Canada—and the disparity with other developed nations is even greater (see figure below). However, disparities in maternal mortality within the U.S. show Black women dying at three times the rate of White women.
    new data shows u.s. maternal mortality rate exceeds that in other high-income countries
    Source: The Commonwealth Fund, 2022
    What’s causing our outrageously high maternal mortality rates—and what can we do about it? Let’s take a closer look at three aspects of indirect policy violence (Murder #2) that contribute to our extreme maternal mortality rates—especially among Black women: lack of access to health care, states with restrictive abortion laws, and lack of access to housing.
    Lack of Access to Health Care Coverage (Medicaid): Women of reproductive age who live in the 12 states where lawmakers have refused to expand Medicaid have significantly higher uninsured rates than women in expansion states—and two-thirds of these women in the coverage gap are people of color. Expanding Medicaid coverage has been demonstrated to lower maternal mortality, improve overall health, and support healthy development of both parents and children, especially among Black women. Simply put, health insurance saves lives.
    Restrictive abortion laws: It’s been one year since the repeal of Roe v. Wade, and evidence shows women living in states with abortion bans are three times more likely to die during pregnancy, in childbirth, or soon after giving birth.  Other studies have found higher rates of maternal mortality and infant death (especially for women of color) and higher rates of death among women of reproductive age in general in states that have restricted abortion. States that restrict abortion are also states that have not historically supported women’s health in general.
    Lack of Access to Housing: It’s no surprise that homelessness is hazardous to a pregnancy. Women experiencing homelessness had significantly higher risks of pregnancy complications and go into pre-term labor more often than non-homeless women (even after adjusting for behavioral health disorders). Also, women facing eviction from their homes while they were pregnant are more likely to have poor birth outcomes. Housing provides the stability needed for a healthy pregnancy (and all other aspects of life).
    “I was living in a vacant home in rural Alabama when I was pregnant, but getting care at the local clinic was not easy. I had to walk to get there, and I went twice to see a doctor and didn’t get help either time. Even though I qualified for insurance because I was pregnant, it took me weeks before I could get coverage and finally get seen by a doctor. The staff at the social services agency encouraged me to keep going back to the local clinic, but it should have been much easier to get the help I needed. I feel like being homeless and not being able to get health care endangered my health.”
    ~ Sandra Mooney, Consumer Engagement Coordinator, NHCHC
    * Important note: Transgender men and non-binary people who are pregnant face significant barriers to prenatal care (and other health care services) that cis-gender women do not. A 2019 LGBTQ Family Building Survey conducted by Family Equality found that 63% of queer and trans people age 18-35 were thinking about expanding their families, whether that meant becoming first-time parents or having more children. Our public policies need to reflect gender equity in pregnancy and childbirth. A prior Closer Look blog focused on the indirect policy violence that LGBTQ+ people often face.
    It cannot go unmentioned that direct physical violence (Murder #1) against pregnant women is shockingly high, largely stemming from intimate partner violence and firearms. 
    What’s Being Done to Address Maternal Mortality
    In June 2022, the Biden Administration released the Blueprint for Addressing the Maternal Health Crisis, which included measures to improve access to coverage and care (to include HRSA funding for maternal health awards). More states are also expanding postpartum coverage for Medicaid—with 35 states and DC now offering a full year of coverage after delivery (though this no substitute for full Medicaid expansion). In April 2023, the Biden Administration lifted up the specific issue of Black maternal mortality by announcing the third annual Black Maternal Health Week to galvanize greater action to address the racial disparities in maternal health outcomes. Some states are also making strides to increase access to a broader array of services and providers that support maternal and infant health, diversify the health care workforce, and enhance data collection and reporting.
    Indirect policy violence continues to murder pregnant women, with an outsize murder rate on Black women. But clearly more needs to be done if we are to drastically lower the U.S. maternal mortality rate and close the immense racial disparity gap among Black mothers.
    Take Action
    • If your state has not yet expanded Medicaid, advocate for full Medicaid expansion as quickly as possible. At the very least, advocate for 12-months of postpartum coverage.
    • Call your federal representatives and ask them to co-sponsor the Medicare for All Act of 2023 bill that would bring the U.S. health care system in line with other developed nations.
    • If your state has restricted access to abortion, advocate for access to comprehensive health care.
    • Tell your federal representatives that the 25% budget reductions to HUD appropriations would only contribute to more homelessness and maternal mortality. Instead, much more should be invested in housing assistance. 
    One Year Post-Roe v. Wade
    It’s been one year since the Supreme Court reversed Roe v. Wade and turned abortion policy back over to states. Now, 15 states ban abortion in nearly all circumstances, creating vast implications for reproductive health care. Increasingly, health care providers in these states are unable to provide high-quality care and are at risk for criminal or civil charges. An initial report shows a wide range of harm to people in states with bans or severe restrictions on abortion care, to include obstetric complications, early miscarriage, and delays obtaining medical care unrelated to abortion.
    As HRSA-funded health care providers, the primary action that the Health Care for the Homeless community can take is to ensure immediate access to voluntary family planning services. The Biden Administration just released an Executive Order to strengthen access to affordable contraception and family planning services. The Order “encourages all federally funded health centers, including HRSA-funded health centers, to expand the availability and quality of voluntary family planning services” and “support access to culturally and linguistically appropriate care, including by developing and disseminating materials on family planning services.”
    Substance Use Issues in the News 
    Research: A new study shows that fatal overdoses increase after police make drug seizures that contain opioids—doubling the rate of deaths within a week in the immediate area. The theory behind these findings is that the usual drug supply is then unavailable, and customers—facing withdrawal symptoms, limited access to treatment, and reduced tolerance—turn to unfamiliar supplies and suppliers. 
    Side-note to all the researchers out there: The title of this study is Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020–2021. If you are hoping to impact public policy and engage advocates and policymakers in constructive drug laws, please consider avoiding titles with terminology that few understand—like “spatiotemporal analysis.”
    Over the counter Naloxone: In March 2023, the FDA approved Naloxone (the overdose reversal medication) for over-the-counter sales. While pharmaceutical companies have been profiting handsomely off this medication for years, it remains unclear how expensive it will be for purchase moving forward. [See this info-graphic that shows 79% of Naloxone’s cost is profit.] The concern over pricing is so acute the White House met with drug manufacturers on June 20 to stress the need for widespread availability and affordability. While costs to the general public are one issue, we remain concerned that market forces will limit naloxone supplies to the public health and safety net community.
    State opioid cash settlements: More than $50 billion is being distributed to state and local governments as part of opioid lawsuit settlements in response to the overdose/addiction crisis (although only about $3 billion has already been allotted). Payments began last year and will continue through 2038. This is the largest public health settlement since the tobacco settlements in the 1990s, and meant to remediate the harms that have been committed to communities across the country. To date, it has not been clear where these funds were going; however, the Kaiser Family Foundation (KFF) has posted the exact dollar amounts by state. However, each state has its own approach to using these funds, including different distributions between local and state governments and various processes for spending the money. Johns Hopkins School of Public Health has outlined five principles for maximizing these funds: spend the money to save lives, use evidence to guide spending, invest in youth prevention, focus on racial equity, and develop a fair and transparent process for deciding to spend the funding.

    Take Action on Substance Use Issues:  

    • Seizures of drugs: Work with your emergency response teams to increase awareness of overdose risks immediately after drug seizures, stock additional naloxone, and increase treatment availability
    • Availability of naloxone: Be on the lookout for any reductions in the no/low-cost naloxone supply to your program as part of safety net/public health interventions/distribution. Let us know if you experience disruptions to this life-saving medication!
    • State advocacy: Use the funding information and the guiding principles to advocate with your state to leverage its funding wisely.
    Partner Resource Highlight: NLIHC 2023 Out of Reach Report 
    Nationally, full-time workers need to earn more than $23 hourly to afford a modest one-bedroom rental, and you would have to work more than 100 hours a week to afford a two-bedroom rental on minimum wage. That’s according to the newest Out of Reach report from our partners at the National Low Income Housing Coalition. Their annual report offers vital wage and rent data that is specific to each state so you can use local data in your advocacy for affordable housing.
    map showing income needs for a modest apartment in each state
    COVID Corner 
    Masking in health care facilities: In case you missed it, the CDC updated its health care worker guidelines in May to make masking optional for health care facilities. Instead of the prior recommendation for universal masking, they now recommend health care facilities use a risk-based assessment, stakeholder input, and local metrics to determine how and when to require masking.
    Climate Change and Homelessness 
    As fires, floods, hurricanes, and extreme temperatures become more common as a result of climate change, the health and safety of unhoused people are especially at risk. As we enter summer, extreme heat is a key risk factor for burns, heat exhaustion, heat stroke, and will complicate existing chronic illnesses. It is also a risk for spoiled food, and will exacerbate the effect of drugs and alcohol. Communities should take the following steps:
    • Provide permanent housing
    • Plan for greater “code red/blue” shelter capacity and more cooling/warming station
    • Increase awareness and educate those living outdoors about how they can protect themselves (see resource below)
    • Incorporate the needs of people experiencing homelessness into state emergency response plans
    • Distribute cold water, fans, bus passes, and other practical items to reduce the impact of the heat
    NHCHC resource on emergency planning: Surviving Severe Weather: Tools to Promote Emergency Preparedness for People Experiencing Homelessness. Share these informational flyers with clients and talk about steps they can take to protect themselves to the extent possible if they are staying outdoors during an emergency. There is also information about planning a training to talk about these issues.
    What We're Reading
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    Barbara DiPietro
    Senior Director of Policy
    National HCH Council
    Baltimore, MD
    (443) 703-1346

    This publication and all HCH advocacy are funded by dues from Organizational Members of the Council and by private donations. Consider joining the Council to support this work.
    604 Gallatin Ave., Suite 106 | Nashville, TN 37206 US
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