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July 27, 2023 | Volume 27, No. 6| Archives

Actually, Some Good Things are Happening Too!

In This Issue: 
  • FY2024 Budget—Where We Currently Stand
  • Medicaid Redeterminations—Most Disenrollments Still for Procedural Reasons
  • Want to Write This Mobilizer? We’re Hiring!
  • A Closer Look: Actually, Some Good Things are Happening Too!
  • Substance Use Disorder in the News
  • Equity and Racism: “Unequal Treatment” Report—Then and Now
  • The Supreme Court and Affirmative Action
  • Partner Resource Highlight: CDC Public Health & Homelessness Toolkit
  • COVID Corner: Vaccine Program Conclusion
  • What We’re Reading
FY2024 Budget — and the Struggle Ahead
    icon of money
    There’s a lot to be said on the budget, but the biggest take-away is that we’re on a collision course between the House and the Senate, with unclear consequences. The debt ceiling deal included an agreement on the cuts that would happen to the FY24 budget (cuts that were more modest than conservatives wanted). Now, the House is trying to make much more significant cuts than the debt ceiling called for (with Freedom Caucus members saying they will refuse to advance any measure without such cuts), while the Senate is moving budget bills forward without those reductions. It will be exceedingly difficult to rectify these differences before the fiscal year runs out on September 30. A continuing resolution may be possible, but if hardliners dig in, it might mean a government shut-down.
    Annual appropriations on health care: Late last week, the House Appropriations Labor-HHS-Education Subcommittee marked up the FY24 Labor, Health and Human Services, and Education bill (bill summary), which provides about 30% of health center funding, and did NOT reduce health centers’ funding below the Fiscal Year 2023 level (despite a 30% cut to the bill’s overall spending level). The bill must now be voted on by the full Appropriations Committee, then the entire House. Meanwhile, in the Senate, the HHS budget is planned to be marked up today, July 27.
    Mandatory health center funding: Separately, the Senate HELP Committee is advancing a bill to fund community health centers and the health care workforce (remember that health centers have both discretionary funding subject to the annual appropriations process, as well as multi-year mandatory funding). Here’s a summary of the draft legislation—which includes investing nearly $66 billion over five years for health centers (a hearing on the bill is being postponed until September). This bill addresses the mandatory funding for the community health center fund, among other provisions.

    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.
    • Schedule a site visit! Lawmakers will be home during August recess. Call their office and invite your representative to your program to illustrate how federal dollars support jobs, health care, and greater stability for community.
    alert sign
    Medicaid Redeterminations — Most Disenrollments Still for Procedural Reasons
    As of July 21, nearly 3.3 million people have been disenrolled from Medicaid. At the highest end, Texas has kicked 82% of its Medicaid enrollees out of the program. Across all states reporting data, 74% of all people disenrolled had their coverage terminated for procedural reasons (such as not receiving a response to a mailed letter). CMS has offered 23 policy options and encouraged states to pause redeterminations to reduce the number of procedural terminations, however, Florida is an example of a state that has refused any assistance. North Carolina* joins many states where the vast majority of its disenrollments are for procedural reasons unrelated to ongoing eligibility. CMS is working actively with states to mitigate the damage, and has the option of imposing fines on states that continue to show poor results.
    (*Remember that North Carolina was supposed to be in the process of expanding Medicaid; however, that hasn’t yet happened and policymakers there continue to stall progress on passing a needed budget measure.):

    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.
    we're hiring!
    Want to Write This Mobilizer? We're Hiring!
    Do you know someone who is passionate about social justice, has experience with legislative advocacy, and would make a great addition to the National HCH Council’s Policy Team? We’re hiring for a Senior Policy Manager and want to ensure we get the word out. More details are in the job description, but this person will staff our Policy Committee, represent us on Capitol Hill, and manage our policy and advocacy agenda (and yes, write this exciting newsletter!).

    Take Action on Advocacy & Ending Homelessness: 

    • If the above description fits YOU, please apply!
    • If you know someone who would be a great candidate, please forward this announcement.
    A Closer Look logo
    A Closer Look: Actually, Some Good Things Are Happening Too!
    By Barbara DiPietro, PhD, Senior Director of Policy
    It’s summer and it’s hot, so let’s take a break from the usual focus on the things that are killing us (literally and figuratively) and instead focus on three things happening in the Medicaid space that are advancing life-affirming policies!
    1. New Code for Street Medicine. It’ll soon be easier for all states to deliver medical care on the street because CMS just issued a new “place of service (POS) code” specific to street medicine. This code will be operational starting October 1, 2023 and is distinct from service codes for mobile units, or services in homeless shelters, in FQHCs, or at public health clinics (to name a few). The code allows services to be billed to Medicaid from “a non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals.”
    The reason this is awesome — according to David Peery, Executive Director of the Miami Coalition to Advance Racial Equity: "Street Medicine saves lives, providing vital health care services to a vulnerable population of unhoused persons who otherwise lack access to health care." 
    This code legitimizes street medicine as a specific discipline that is a recognized part of the health care system nationwide. Soon, street medicine visits can be uniquely identified for purposes of managed care contracts with different rates and scopes of work as well as to allow for out-of-network referrals to be approved more easily. Also, the ability to uniquely identify street medicine visits (and patients) will allow better data collection and a greater understanding of the needs of people experiencing unsheltered homelessness. Ultimately, this code can also help inform the creation of a more equitable care model.
    2. “Re-entry” Waivers from Jails/Prisons: In April 2023, CMS released a State Medicaid Director Letter providing guidance on a new Medicaid Reentry Section 1115 Waiver Demonstration Opportunity that would allow state Medicaid programs to cover a targeted set of services during the period immediately preceding release from prison or jail. The goal of this waiver opportunity is to increase continuity of coverage and care, access to services, coordination between correctional and community systems, investments in health care to improve quality of care, and improve post-release outcomes. Eligible individuals are people who will be leaving state prisons, jails, and youth correctional facilities. Services can be provided for up to 90 days prior to a person’s expected release date. CMS stipulates three benefits that states must provide: case management to address physical, behavioral health needs and health-related social needs (HRSN); medication-assisted treatment (MAT) for substance use disorders; and a 30-day supply of prescription medications upon release. States may propose benefits above and beyond this minimum.
    California and Washington State have already requested this waiver and been approved, while 13 additional states have proposed waivers to CMS to cover pre-release services for adults: Arizona, Kentucky, Massachusetts, Montana, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Utah, Vermont, and West Virginia (as of June 2023). 
    Also — in case you missed it — last year's budget bill out of Congress (the Consolidated Appropriations Act of 2023) requires all states starting Jan. 1, 2025, to cover screenings, service referrals, and case management for children  children and youth who are incarcerated for 30-days prior to their release. It also gives states the option to offer Medicaid-covered services to juveniles who are incarcerated prior to adjudication.
    The reason this is awesome: For the first time, CMS is authorizing more Medicaid-reimbursable services to those “behind the wall”—and requiring screenings/referrals/case management for youth in all states. As we know, Medicaid is often terminated upon incarceration and jail/prison health care is frequently woefully inadequate to meet the needs of a population with high rates of medical and behavioral health conditions. Hopefully this step starts a process of better integrating jail/prison health with better health outcomes. The fact that many states have already applied for this waiver is heartening!
    3. Washington State’s New Medicaid Waiver: Washington just received federal approved for a new five-year waiver that includes continuous eligibility for postpartum individuals, presumptive eligibility for home and community-based services, contingency management, supports for community reentry, and services addressing health-related social needs (HRSN), while continuing initiatives related to continuous eligibility for children, eligibility for alternative long-term services and supports, existing services addressing HRSN, and treatment for substance use disorder (SUD) and serious mental illness (SMI). All this AND medical respite care, short-term post-hospitalization housing, and six months of short-term housing.
    The reason this is awesome—according to Rhonda Hauff, CEO of Yakima Neighborhood Health Services: “The Washington Medicaid Transformation Project, affectionately called “MTP 2.0,” provides greater opportunities for health centers to support and improve the health of people experiencing homelessness specifically providing Medicaid coverage for medical respite care (what we once considered an unreachable dream!), housing supports, and even housing deposits and short-term rent subsidies. It allows us to work upstream by supporting people at risk of homelessness before they become unsheltered. The expansion of Supportive Housing and Supported Employment (Foundational Community Supports), both evidence-based models that demonstrate improved health and quality of life, will hopefully encourage more health centers to integrate housing with primary health care services.” 
    Note: Washington is part of a wave of states requesting Medicaid reimbursement for medical respite care. They also join Arizona and Oregon in getting permission to use Medicaid funding for six months of rent.  
    addiction, drug use
    Substance Use Disorder in the News
    • Draft SAMHSA Harm Reduction Framework: SAMHSA’s new Harm Reduction Framework is the first document to comprehensively outline harm reduction and its role within HHS. The Framework will inform SAMHSA’s harm reduction activities moving forward, as well as related policies, programs, and practices. SAMHSA is seeking comments on this framework—due August 14. Access the document here.
    • Criminalizing fentanyl: Despite protests from public health advocates, 28 states have enacted at least one law that criminalizes fentanyl in some way. While they vary, the bills generally would increase (or strengthen) penalties for illegal production, possession and distribution (Texas is the latest state to pass such a law). Great quote in the Stateline article above: “If you make illegal things that human beings want, you will make things worse…You will create more organized crime, you will create more unintended consequences, you will create more disparity and destruction in poor communities, because this crap never affects the communities of the people who make the laws."
    • Overdose rates: Between 2011-2021, CDC data shows the rate of overdose deaths involving opioids and cocaine nearly quintupled, far outpacing the rate of deaths involving only cocaine. In 2021 alone, nearly 80% of cocaine overdose deaths also involved an opioid. Early data shows the overdose rate in 2022 decreased slightly (by 2%), but still accounted for 105,452 deaths.
    • Buprenorphine study: Alas, in spite of numerous efforts to increase access to buprenorphine—to include removing the X-waiver requirement—a new JAMA study shows rates of prescribing have not meaningfully changed. Ongoing concerns include DEA overreach, insurance approval processes, lack of institutional support,  buprenorphine misuse, and treating patients with opioid use disorder.

    Take Action on Substance Use Issues:  

    • Comment on the SAMHSA Framework! Deadline is August 14.
    • Continue advocating for access to treatment using a low-barrier, harm reduction approach and push back on criminalizing drug use.
    • Maximize your program’s use of buprenorphine and other medications for opioid use disorder. Use our policy brief for key strategies.
    Sign: End systemic racism
    Equity and Racism: "Unequal Treatment" Report — Then and Now 
    20 years ago, the landmark report “Unequal Treatment” detailed the racial and ethnic disparities in health care and was the first major report to point to racism — not lack of insurance, poverty, or refusal to seek care — as a major factor in causing health disparities. Unfortunately, not much has changed, and national experts are convening the “Committee on Unequal Treatment Revisited: The Current State of Racial and Ethnic Disparities in Health Care” to update this report and reinvigorate recommendations to finally achieve health equity. Health equity experts are pointing to the critical need to fundamentally change how health care systems are financed, the need for financial penalties for poor outcomes, and the need to overturn income inequality and racial segregation. The Committee is inviting the public to share their experiences, thoughts, and ideas about racial and ethnic disparities in health care. (Unfortunately, no deadline for submissions is listed.)

    Take Action on Racism:  

    • Share your (or your family member’s) experience with racial disparities in health, the interventions you believe the Committee should consider, or other stories you have about racial and ethnic disparities in health care.
    • Forward this call for perspectives to those you believe can share their own story about racism in health care.
    Person holding sign: Diversity is a necessity
    The Surpreme Court and Affirmative Action 
    On June 29, the Supreme Court ruled it was unconstitutional for colleges and universities (as well as professional schools for law, medicine, and nursing) to use race as a factor in student admissions. This decision severely impacts the affirmative action initiatives that higher education has been using to diversify admissions, and will almost certainly mean that fewer Black, Indigenous, and People of Color are able to obtain college or advanced degrees.
    For the health care field, this decision also undermines goals to diversify the health care workforce, and ensure that providers look more like the patients/clients they are serving. It also means fewer opportunities for BIPOC staff to achieve advanced degrees in their field. An analysis of existing bans in six states found that medical school enrollment of students of color fell roughly 17% after the bans were instituted. 
    Curiously, legacy admissions—mostly benefiting White students—continue to be legal. (Just sayin.)
    Person holding sign: Diversity is a necessity
    Partner Resource Highlight: CDC Public Health & Homelessness Toolkit
    The Centers of Excellence in Public Health and Homelessness Toolkit for State and Local Health Departments: The toolkit provides strategies, best practices and other resources to assist health departments serving people experiencing homelessness. It includes sections dedicated to building and strengthening partnerships, engaging people with lived experience, ensuring equity, prioritizing infectious diseases and data modernization.
    COVID Corner: Vaccine Program Conclusion 
    On August 23, 2023, the Health Center COVID-19 Vaccine Program that allowed health centers to receive COVID-19 vaccines directly from HRSA will end. Once the program concludes in August, health centers will need to access COVID-19 vaccines through their state or jurisdiction vaccine supply. HHS recently announced the Bridge Access Program for COVID-19 Vaccines and Treatments. This new program has two major components: to provide support for local health departments and HRSA-supported health centers and to create a partnership with pharmacy chains to allow continued free COVID-19 vaccines and treatments to the uninsured.
    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.
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