When the coronavirus pandemic battered the U.S. health care and public health systems, it exposed crippling deficiencies. Hospitals and providers staggered under the weight of infection surges, and long-term care facilities struggled to keep vulnerable residents safe. Communities of color suffered disproportionate disease and death tolls, highlighting long-standing health disparities.
The pandemic “really has elevated [health care] to the front line as a priority. You realize you’re not prepared for a pandemic,” says South Carolina Senator Thomas Alexander (R), who is vice chair of NCSL’s Health and Human Services Committee. “It has unified us, because across party lines, we want to take care of the health needs of the citizens.”
(The pandemic) has unified us, because across party lines, we want to take care of the health needs of the citizens. —South Carolina Senator Thomas Alexander, vice chair of NCSL’s Health and Human Services Committee
As the worst of the pandemic recedes, state policymakers are exploring ways to fill the gaps and make improvements—through changes to health care coverage and payment, workforce strategies and public health capacity, among others—to strengthen the system for the next crisis.
Ensuring Access to Health Coverage
As the U.S. economy cratered and unemployment reached its highest level since 1940, job losses disrupted health coverage for nearly 15 million Americans and their families who were covered through their employers. Loss of employer-sponsored coverage during the pandemic affected enrollment in other coverage, such as Medicaid and marketplaces.
The pandemic “exposed the big vulnerabilities of an employer-based health insurance system, that as people were losing their jobs because parts of the economy were shutting down, they were losing their health insurance along with it,” says Colorado Representative Yadira Caraveo (D), who is a practicing physician. “I saw a lot of people who dropped off from bringing their kids in to see the doctor, even for regular checkups, either because they were having health insurance issues or because they were just short on money and were trying to cut back on things.”
With loss of other coverage, Medicaid enrollment surged during the pandemic. “Medicaid has transformed how we think about public health and how we deliver health care services and the disproportionate impact that it does have on low-income communities and communities of color,” says Minnesota Representative Rena Moran (D).
The federal government tied fiscal relief for Medicaid programs to continuous coverage requirements to ensure individuals would not lose health coverage during the pandemic. States also eased eligibility requirements to help ensure individuals timely access to Medicaid coverage through mechanisms like self-attestation of eligibility criteria, particularly for income, and streamlining enrollment using presumptive eligibility.
In a post-pandemic period, even with economic recovery, Medicaid enrollment may remain inflated as the recovery tends to reach low-income individuals more slowly. The continuous coverage requirement remains in effect for the duration of the public health emergency, which is expected to be extended through the end of 2021. As that period ends, state policymakers—who may be facing fiscal pressures from inflated Medicaid enrollment as well as potentially newly uninsured populations—will be tasked with decisions around Medicaid benefit coverage and service delivery options to control costs and improve efficiencies.
States and the federal government are also looking to increase access to and affordability of marketplace coverage for millions of Americans. The American Rescue Plan of 2021, the latest COVID-19 relief bill enacted in March, temporarily expands advanced premium tax credits for marketplace plans, making plans more affordable for many consumers. This increase in affordability, paired with an extended special enrollment period to purchase these plans, will likely increase marketplace enrollment going forward.
Reforming Health Care Delivery
With COVID cases overwhelming hospitals and acute care facilities, other health care facilities became financially strained as routine care and elective procedures were delayed—exposing their financial vulnerability. It is important to “remember that private practices are small businesses, and every kind of small business was affected during the pandemic,” Caraveo says.
State policymakers may continue to look toward value-based care arrangements to bolster financial sustainability while also reigning in costs to pay for value. While there are concerns COVID delayed value-based care implementation efforts, some policy experts maintain certain models, like global budgets in the Pennsylvania Rural Health Model, shielded providers from steep revenue losses due to drops in elective procedures.
Policymakers, providers and consumers also embraced telehealth to ensure continuity of care during the pandemic. “I think a lot of providers who were uncomfortable using it, including myself, had to use it this year, and it worked really well,” says Kentucky Senator Ralph Alvarado (R), another practicing physician. “I think people felt comfortable, patients felt comfortable, providers did, and it led to a lot of expansion of telehealth.”
All 50 states made some modification, either permanently or temporarily, to their telehealth policies during COVID, with many doing so legislatively. States including Colorado and Mississippi expanded telehealth services through Medicaid; while others, such as Massachusetts, further addressed payment for services delivered through telehealth. And many states, including Delaware and Kentucky, streamlined licensing requirements for out-of-state providers using telehealth.
The uptake in telehealth “really pointed out that in order to have big changes in health care, you have to make it a budget priority as well, because the second that telehealth was reimbursed, it was picked up and it has transformed the system,” Caraveo says.
COVID restrictions also changed how pregnant women receive prenatal care and give birth. State efforts to expand telehealth coverage and access during the pandemic allowed pregnant women to continue care, with many providers considering a permanent shift in prenatal care practice.
Although some states made some COVID-inspired telehealth changes permanent, others simply extended flexibilities while policymakers consider which modifications should stick around.
Addressing Provider Workforce Shortages
The COVID pandemic created an unprecedented demand for health care providers in states already facing workforce shortages. Policymakers continue working to increase the number of providers to support the ongoing response and plan for the future. The crisis will “give us an opportunity to look at regulations and if we are having barriers to entry and to professions in health care and other arenas as well,” South Carolina Senator Alexander says.
During the pandemic, all 50 states modified or waived some aspect of providers’ scope of practice to temporarily increase access to care, especially for those living in rural areas. It remains to be seen whether states will make these changes permanent.
During the pandemic, all 50 states modified or waived some aspect of providers’ scope of practice to temporarily increase access to care.
Many states are examining practice authority for some medical professionals to expand access to care. For example, Arkansas, Florida, Utah and Wyoming now allow nurse practitioners or physician assistants to practice without the supervision of a physician after completing certain requirements. Virginia reduced the number of years from five to two before an N.P. can practice independently. Delaware and West Virginia changed their policies to allow for collaboration between a P.A. and a physician, instead of a supervisory relationship.
To expand the perinatal workforce and provide additional options for delivery, Maine, New York and Pennsylvania issued emergency orders to expand midwifery care. This follows a broader trend of addressing workforce shortages by licensing direct entry midwives, as the District of Columbia did, and expanding scope of practice for nurse midwives, which Arkansas enacted.
Additionally, all 50 states and D.C. made temporary changes to the way they regulate certain health care professions through executive order. While many of those orders have since lapsed, legislators have jumped in to continue this work. Some states that saw success during the pandemic with temporary and provisional licensure are now considering legislation to expand them to new professions. For example, New Mexico now allows temporary licensure for behavioral health practitioners working toward a New Mexico license if they are licensed and in good standing in another state.
Finally, legislators continue to look at ways to reduce barriers to mobility for licensed workers. Adopting universal licensure or recognition laws was popular before the pandemic and continues to be in 2021.
Improving Care for Those With Greatest Need
Long-term care facilities were early hotspots for COVID-19 outbreaks, and their residents were particularly susceptible to severe illness and death. While cases in these facilities have decreased since the start of the crisis, policymakers are examining how lessons from the pandemic will shape long-term care delivery into the future.
Federal and state policymakers have focused on safeguarding residents and staff while also ensuring access to essential services. Some states are pursuing innovative technologies to remotely engage with residents. In Kentucky, the long-term care ombudsman is purchasing equipment to help residents communicate with their families, which could address feelings of social isolation.
States are also examining new strategies to recruit, retain and protect the direct care workforce—personal care aides and certified nursing assistants, among others—who provide most long-term services and supports. “(Nursing home facilities) tried to follow appropriate guidelines, but they just didn’t have enough personnel,” Kentucky Senator Alvarado says.
Some states, such as Pennsylvania, increased some payments to account for excess overtime of direct support professionals.
COVID exacerbated and highlighted significant existing health disparities by race and ethnicity, with disproportionately higher rates of illness, hospitalization and death among Hispanic, Black, American Indian/Alaskan Native, and Native Hawaiian and other Pacific Islander people. “The pandemic laid bare the inequities in health disparities among BIPOC (Black, Indigenous and people of color) and Asian communities, including the prevalence of preexisting conditions, like heart disease, diabetes, high blood pressure, asthma,” Moran says.
States are responding in a multitude of ways: Louisiana and New York are studying the issue; Massachusetts and Pennsylvania are requiring data collection by race and ethnicity; North Carolina, South Carolina and Vermont are earmarking funds for communities hardest hit by the virus; and Nevada is declaring systemic racism a public health crisis. These actions align with a larger public health effort to use data, identify interventions and address the role of racism and discrimination to close gaps in health outcomes.
States are also trying to remove barriers to testing and vaccinations by traveling to different populations to provide services. South Carolina is expanding mobile health, including vans for testing and vaccines, Alexander says. “Rather than waiting for the people to come to us, let’s go to the people. Hopefully, that’s something that will continue.”
Clinicians care for COVID patients in a makeshift intensive care unit at Harbor-UCLA Medical Center in Torrance, Calif., in January. The hospital was over its ICU capacity and was forced to treat patients in rooms designed for lower levels of care. Some states are exploring ways to fund improvements to prepare for future pandemics.
Expanding Behavioral Health Services
The pandemic and the resulting economic recession negatively impacted many people’s mental health and created new barriers for people with existing mental illness and substance use disorders. Measures meant to mitigate the spread of the virus, such as social distancing and stay-at-home orders, could be contributing to adverse mental and behavioral health experiences. “What we don’t know yet is the impact of behavioral health and addictions,” Alexander says.
States are modifying telehealth policies and leveraging federal flexibilities to increase access to telebehavioral services, including distance counseling via audio-video conferencing. For instance, Louisiana expanded the types of health providers who can perform telepsychiatric evaluations, and Kentucky loosened requirements around audio-only telehealth visits, including for telemental health. “We were requiring audio-visual for everything, and we realized that some things, particularly mental health counseling, can be done audio only,” Alvarado says.
The Drug Enforcement Administration also updated guidance to allow more flexibility for medication-assisted treatment prescribers, and some states have codified these flexibilities into law. Vermont, for example, authorized certain health professionals to renew a patient’s existing buprenorphine prescription without requiring an office visit. Buprenorphine is a medication used to treat opioid addiction and acute or chronic pain.
States are working to ensure access to opioid overdose antidotes, such as naloxone, as people who use opioids may have increased risk of overdose during the pandemic. New Hampshire and Virginia supported financing for the drug’s distribution and administration.
Many essential workers face greater risk of contracting COVID than nonessential workers and are more likely to report negative mental and behavioral health outcomes, according to the Kaiser Family Foundation. Florida and Pennsylvania lawmakers passed similar bills requiring or urging their state insurance departments to waive certain costs for mental health services provided to front-line health care workers. New Jersey and Nevada have provided psychiatric service dogs to help front-line workers with PTSD and have set up hotlines for workers to connect with mental health professionals.
Enhancing Public Health Capacity and Response
State health agencies and legislatures worked overtime throughout the pandemic to support response efforts with innovative testing, contact tracing and vaccination efforts, while maintaining other important public health functions. Coordination between public health and health care, as well as other partners such as the National Guard—mobilized in Pennsylvania and Washington—has been essential during the response.
New Jersey and Utah reviewed how deaths and cases were reported and have made significant strides to improve the speed and quality of public health reporting for the pandemic and for future outbreaks. While health agencies have utilized contact tracing for decades for several diseases, including tuberculosis and HIV, South Carolina and New York scaled up their efforts and refined policies to ensure privacy protections or certain training for contact tracers.
Some states, including California, Georgia, New Jersey and South Carolina, are exploring ways to enhance or maintain their public health functions by funding systems improvements for current and future pandemics. Others, such as California and North Carolina, are ensuring they are better prepared for future outbreaks with stockpiles of items such as personal protection equipment and testing supplies, or they’re ensuring health care professionals are equipped with certain emergency management tools, as Arkansas has.
Looking to the Future
As the nation emerges from the pandemic, there are increasing signs of promise. The unemployment rate has dropped significantly since last spring, millions of Americans are getting vaccinated every day, and states are lifting COVID-related public health restrictions. Federal and state policymakers and other stakeholders are leveraging lessons learned from the pandemic to improve the health care system now and in the future. “I think that the biggest opportunity is that we have this knowledge now of what went well and what didn’t go well, in the health care system in particular, and in all of our systems overall,” Colorado Representative Caraveo says.
While many changes have been made to health care payment, coverage, delivery, workforce and systems, improving health and health care is a long game.
“I really hope this is going to be a road map for a bright future,” South Carolina Senator Alexander says. “People can look back 50 years from now, or 100 years from now, and say, ‘They really did a great job in preparing for the citizens that were going to come after us.’
“This is an opportunity to move forward in a visionary way.”
Kelly Hughes is an associate director in NCSL’s Health Program.
This story was first published in the Summer 2021 edition of State Legislatures magazine.