Since 2021, Georgia Watch, Georgians for a Healthy Future (GHF), and SOWEGA Rising have worked to protect consumers in Southwest Georgia from unaffordable medical bills and debt through the Community Benefit and Economic Stability – Georgia (CBES-GA) project with support from leading health advocacy organization, Community Catalyst. Southwest Georgia experiences medical debt at a higher rate than the rest of Georgia and the country, particularly in communities of color. Southwest Georgia also has some of the highest insurance premiums in the country due primarily to the lack of competition among providers and insurers. This level of consolidation leaves consumers with little choice about where to seek care and incentivizes predatory medical billing practices. In Dougherty County, 25% of black residents have a medical bill in collections, compared to 21% in Georgia and 17% nationally (Urban Institute, 2020), creating significant barriers to care and trapping already cash-strapped Georgians into a cycle of poverty.  

“The medical debt burden disproportionately impacts black and brown people due to unfair and discriminatory barriers to health coverage and economic security, noted Sherrell Byrd, Executive Director of SOWEGA Rising. “Particularly in rural Georgia, you will see the highest rates of medical bills which drives up insurance costs, creating barriers to people who have to choose between paying bills and seeking necessary medical care.” 

Leveraging the policy expertise of Georgia Watch and GHF, as well as the local knowledge and community trust of SOWEGA Rising, the CBES-GA team has aimed to protect consumers in Southwest Georgia from unaffordable medical bills and debts so that all Georgians can afford the care they need. As this phase of the project winds down in the summer of 2022, we are reflecting upon all we have accomplished and how we will continue the work.

Si busca estar a la moda, saludable e inteligente este verano, es hora de hablar sobre las vacunas COVID-19. La Gerente de Comunicaciones y Proyectos Especiales de GHF, Michelle Conde, recibió sus inyecciones de la vacuna esta primavera. Aquí comparte su experiencia y por qué recomienda que otras personas también se vacunen.

If you’re looking to be on trend, healthy, and smart this summer then it’s time to talk about COVID-19 vaccines. GHF’s Communications & Special Projects Manager, Michelle Conde, got her shots this spring. Here she shares her experience and why she recommends others get vaccinated too.

 Georgians for a Healthy Future (GHF), the Georgia Council on Substance Abuse (GCSA), and the Center for Pan-Asian Community Services (CPACS) are nonprofits focused on building healthier communities. We partner together to promote policies and systems that increase access to substance use and mental health prevention, identification, and recovery services for Georgia youth. 

The pandemic has dramatically shifted the lives of Georgia’s children and families. Children have faced inconsistent and uneven access to school, social isolation, and family stressors (from job loss, illness, or other changes). The potential impacts of these challenges are compounded for vulnerable youth, such as those in low-income families, in communities of color, or LGBTQ+ youth. The changes and challenges over the last year could result in or exacerbate mental illness or substance use disorders among Georgia students. 

According to the Centers for Medicare and Medicaid Services (CMS), COVID-19 has drastically reduced the utilization of mental health services among Medicaid & Children’s Health Insurance Program (CHIP) beneficiaries. In 2020, there was a 34% decline in the number of mental health services used by children under 19. Nationally, this decline means that 14 million fewer mental health services were provided to CHIP enrollees.1 The decline in services means that many fewer young people are receiving needed substance use and mental health services, leaving them ill-prepared to return or continue their educations successfully. Additionally, many students lost a critical lifeline for receiving mental health and substance use services during school closures.2 Prior to the pandemic, over one in three young people relied on schools as their primary source of mental health care. 

School-based substance use and mental health services are critical to ensuring that Georgia’s children have access to the services they need. Such school-based care is essential for ensuring young people are healthy and ready to learn, especially as we build back from the downstream effects of the COVID-19 pandemic. 

Georgians for a Healthy Future, the Georgia Council on Substance Abuse, and the Center for Pan-Asian Community Services offer the following comments with respect to the Georgia Department of Education’s utilization of ESSER funds to address the behavioral health needs of Georgia’s children, with a special focus on substance use prevention and treatment. 

Training School Staff on Substance Use and Mental Health 

School districts should train school health personnel and staff (i.e. school counselors, social workers, and nurses) to identify substance use and mental health needs as students return to the classroom and properly refer them to appropriate services, including community mental health and substance use providers. Identifying substance use and mental health issues early, allows students to get the treatment they need before the situation turns into an emergency. 

One evidence-based technique is SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment. SBIRT is low-cost, effective, and supported by the American Academy of Pediatrics. SBIRT helps trusted adults (like teachers, school nurses, or counselors) to have structured conversations that identify students’ drug or alcohol use and connects them to follow-up counseling or treatment if needed. Georgia policymakers have also demonstrated their support for SBIRT by adopting Senate Resolution 1135 during the 2018 legislative session, which endorses SBIRT as a “best practice to facilitate academic success and positive school climate.”3 SBIRT can also be combined with other screening tools that may only address depression, anxiety, or other mental health needs so that a student’s full spectrum of needs is addressed. 

Some related training for teachers and other school staff is beginning through the Opioid Affected Youth Initiative grant program from the Criminal Justice Coordinating Council (CJCC). With their OAYI grant, GCSA is already working with the Department of Education to identify high schools in each of the sixteen (16) RESAs that are most in need of training to have compassionate and constructive with their students who either experience overdose and come back to school, or with students who have friends or loved ones who do not survive overdose. This curriculum will serve as a foundation to build the strengths of each participating school, boost their confidence in having these difficult conversations with students about substance use, and lay the groundwork for similar trainings that focus on prevention and early intervention. The program is currently operating in 16 high schools throughout the state. With additional funds from ESSER, the program could be expanded to more schools, additional school staff could be trained, and participants could be trained for conversations that range from prevention to early intervention to support after overdose. 

Implementing SBIRT Pilot Projects 

Pilot projects to address students’ substance use and mental health needs are an innovative and effective use of the time-bound funding appropriated to the state through ESSER. Specifically, we encourage DOE to use the funding to implement SBIRT pilot projects in all Georgia high schools. 

GCSA has successfully implemented two SBIRT pilot projects, one at Marietta High School and one at Decatur High School, that demonstrated the effectiveness of providing SBIRT in high school settings. In both projects, local community members in recovery from substance use were embedded in the schools to lead the substance use screenings and conversations with students. 

SBIRT pilot projects would allow schools to screen students at risk for substance use; provide opportunities for school staff to learn strategies and interventions for addressing substance use; tailor the screening and brief intervention model to the specific needs of a school; capture data and lessons learned for implementing the program successfully throughout the state; and allow schools to adopt sustainable funding mechanisms to support the programs long-term.4 

Sustainable Investments in School-Based Health Services to Address Substance Use 

In 2018, Georgia submitted a State Plan Amendment (SPA) to CMS to remove the Individualized Education Program (IEP) requirement for school nursing services and allow school districts to bill for school nursing services provided to all Medicaid-enrolled students. Implementing this SPA would bring in additional revenue from the federal government and increase resources for schools to address student substance use.5 For example, if the SPA were implemented and the SBIRT pilot projects were successful, school Medicaid reimbursements could cover the cost of sustaining the program. The SPA is currently on hold, but if the state revived it, ESSER funds could be used to cover the costs of setting-up the program, thus making the funding more sustainable. We encourage DOE to collaborate with the Department of Community Health to revisit the SPA and leverage ESSER funds to implement the change. 

Georgia’s Medicaid health insurance system covers many different Georgians, including those with disabilities. The coverage provided to people with disabilities offers much-needed support to individuals and families that might otherwise fall short of addressing their health care needs.

While Medicaid has been a lifeline for some, a full expansion of Medicaid would bring additional funding to the state and strengthen existing programs. For every dollar Georgia would spend to close the coverage gap, Georgia would receive up to $9 in federal funding. The recently passed American Rescue Plan added to the financial incentives available under Medicaid expansion; under the new federal law, Georgia could attract $1.3-$2 Billion to cover the costs of expansion and offset state spending on other priorities.

This additional funding could benefit Georgians who need Home and Community-Based Services (HCBS) Medicaid waivers. HCBS waivers help people with disabilities get the health and support services they need so they can live independently in their communities, rather than in nursing homes or long-term care facilities. Currently, more than 6000 Georgians sit on a waiting list for one of these waivers.  The additional funding that Georgia could earn under Medicaid expansion could reduce or possibly eliminate the HCBS waiver waiting list altogether.

Below is a first-hand account from a Georgia mother, whose 9-year-old daughter is covered by Medicaid. Her daughter was diagnosed with Ataxic Cerebral Palsy at 18 months. Since her diagnosis, the two have navigated challenging care and coverage issues. Their experiences highlight a number of the policy and advocacy issues that consumers contact GHF about regularly: Medicaid, Medicaid expansion, difficulty finding health care providers, Georgia’s public health system.

Population-based approach

We commend the Department of Community Health for taking a population-based approach to improving the health of Georgia’s Medicaid members. We are especially encouraged by the Department’s commitment to engaging with the care management organizations (CMOs) to monitor and improve racial health disparities among Medicaid members. This commitment is a strong first step, and we believe DCH could go even farther to address and improve health disparities in these three ways:

Planning for Healthy Babies

Planning for Healthy Babies (P4HB) is an important program to improve maternal and infant outcomes and address health disparities, but it serves only a small population of women in Georgia. One of the reasons P4HB is so successful is the targeted outreach efforts to women in areas with poor infant health outcomes. DCH should take a similar approach for all Medicaid eligible populations. By focusing CMO and DCH outreach efforts on areas of the state with poor health outcomes and high Medicaid-eligible populations, they may be able to make a similar impact on health disparities for a larger population.

Meaningful engagement with Medicaid members

To successfully reduce health disparities, we advise DCH and the CMOs to work closely and meaningfully with Medicaid members and community members from the populations experiencing the greatest health burdens to craft impactful strategies tailored to a specific group. There are great opportunities to close racial health gaps among Georgia’s Black & Hispanic communities especially. Georgia has the 2nd largest Black/African American population in the U.S.(The Office of Minority Health, 2021), and 15% of Black Georgians are uninsured (KFF, 2020). Georgia also has the 9th largest Hispanic/Latino population in the U.S., and 47% of Georgia Hispanics are uninsured (The Office of Minority Health, 2021). Black and Hispanic Georgians suffer from chronic and infectious diseases, including COVID-19, at rates higher than those of white Georgians CDC, 2021) and have shorter life expectancies ( The Office of Minority Health, 2021).

Unique barriers (including language, systemic inequities to build wealth, available pathways to coverage, immigration status, social discrimination, and more) block these groups from equitable health status and outcomes. These complex and long-standing barriers to health can only be overcome with meaningful, sustained engagement with members of these and similar groups. Based on GHF’s observations, the infrastructure that DCH and CMOs have for engaging members falls short of what is needed. (GHF humbly offers its assistance to all interested parties re-thinking engagement strategies and programs.)

Beyond language and cultural competency

The Quality Strategy points to translation and language services and cultural competency as strategies to reduce health disparities. These are important components, but they are not sufficient on their own. We encourage DCH to explore additional interventions that better address the root causes of disparities. These interventions could include maximizing the roles of the state’s community health workers (CHWs) and peer support coaches; and incentivizing CMOs to operate robust wrap-around service programs to address housing, food, transportation, and economic needs of members. Numerous studies have shown that CHWs and peer support coaches can play meaningful roles in improving health outcomes, lowering health spending, and reducing health disparities (Chan, 2021).

Another solution to reducing health disparities is to ensure every Georgian has a pathway to health coverage. Medicaid expansion would go farther than the proposed Pathways 1115 waiver towards accomplishing this. Several studies have shown that full expansion of

Medicaid (up to 138% FPL) narrowed disparities in health outcomes for Black and Hispanic individuals, particularly related to infant and maternal health (KFF, 2020). While this decision does not lay with the Department of Community Health, your leaders and staff are trusted and important messengers to state lawmakers about how such a move could improve the health of Georgians.

Behavioral health

We were encouraged to see the Quality Strategy call out behavioral health as an area of focus. Data before and during the pandemic supports that behavioral health needs are growing across the population, and there is no doubt that this holds true for Medicaid members.

However, the measures for Goal 1.5 predominantly address mental health (increase screening for depression among adults and adolescents), while largely ignoring substance use. We know that youth substance use is a risk factor for other issues, including school absenteeism, depression, and committing acts of violence. Data show that Georgia youth are experimenting with drugs and alcohol at younger ages (SAMSA, 2019). Therefore, DCH could significantly impact the behavioral health outcomes of young members by adding measures related to substance use screenings and referral to treatment services. To increase screening for substance-use disorders among youth, DCH could leverage CHIP funds for Health Service Initiatives. Utilizing these funds would provide sustainable funding for school-based or population-based services to address substance use.

Access to care via telemedicine

The increased utilization of telemedicine during COVID-19 has proven it is an important method of care for Georgia consumers, including Medicaid members. For that reason, we are pleased to see it identified in the Quality Strategy. However, telemedicine cannot overcome all access challenges because many Medicaid members live in areas with limited internet connectivity, especially those who live in communities of color and rural communities. We encourage DCH to look for additional methods to increase access to care, including addressing transportation gaps.

Notably, the Quality Strategy does not mention the Non-Emergency Medical Transportation benefit for Medicaid enrollees. In our experience, many enrollees do not know about the NEMT benefit and therefore do not make use of it. Additionally, at times NEMT is unreliable and unprepared to meet members’ transportation needs (i.e., sending a regular van to pick up a member who needs a wheelchair-ready van or sending transportation that cannot accommodate a child’s sibling). DCH could increase access to care by promoting the benefit to more beneficiaries and investing in improvements to the program.

Measurement, evaluation, and enforcement

GHF applauds the strong evaluation and enforcement measures included in the Quality Strategy. The inclusion of the value-based purchasing program in the GF 360º program and the intermediate sanctions policy offer strong accountability measures for Georgia’s CMOs.

We were further pleased to see multiple measures of network adequacy, including appointment availability, incorporated into the Quality Strategy. GHF views appointment availability and travel time/distance as perhaps the most accurate measures of network adequacy in terms of increasing access to care. We encourage DCH to hold these measures above other measures like provider member ratios. To meaningfully ensure network adequacy for Medicaid members, we encourage DCH to adopt more robust enforcement measures for these requirements. Specifically, DCH could leverage intermediate sanctions against CMOs with provider directories that are out-of-date or otherwise inaccurate. Requiring CMOs to maintain up-to-date and accurate provider directories will help ensure Medicaid enrollees can receive timely care and avoid costs associated with unknowingly utilizing out-of-network providers.

Last month, GHF welcomed Whitney Griggs as our new Health Policy Analyst and Knetta Adkins as our new Organizing Manager. Whitney will lead GHF’s research, data, and policy analysis work so that GHF remains evidence-based and data-driven. Knetta will build and grow GHF’s outreach and organizing efforts, keeping GHF in touch with the most important health care stakeholders—Georgia’s health care consumers.

Having access to transportation is crucial to having access to health care. Each year millions of Americans miss or delay health care because they do not have a way to get there.

Medicaid’s non-emergency medical transportation (NEMT) program helps bridge the gap between home and the doctor’s office for individuals who are covered by Medicaid. In 2018, 396,000 Georgians got to their health visits using the free NEMT benefit.

In partnership with The Arc Georgia and the Georgians in the Driver’s Seat initiative, Georgians for a Healthy Future (GHF) staff have spoken with consumers around the state about their transportation needs and the NEMT program.

Legislative update: Sine Die

Thank you for your continued readership and support during the 2021 legislative session! The GHF team is proud to deliver timely, accurate updates to you on health care happenings at the Capitol. We hope that they have helped you stay informed and connected. If you have enjoyed reading each week’s edition, please consider supporting our work with a donation today. Thank you very much!

In this week’s update:

• Our priorities: “Express lane” Medicaid, telehealth, and prior authorization
• Status update: Which bills continue to the Governor’s desk and which ones were left behind
• GHF’s got you covered this session!

Legislative update: Sine Die

Thank you for your continued readership and support during the 2021 legislative session! The GHF team is proud to deliver timely, accurate updates to you on health care happenings at the Capitol. We hope that they have helped you stay informed and connected. If you have enjoyed reading each week’s edition, please consider supporting our work with a donation today. Thank you very much!

In this week’s update:

• Our priorities: “Express lane” Medicaid, telehealth, and prior authorization
• Status update: Which bills continue to the Governor’s desk and which ones were left behind
• GHF’s got you covered this session!