Blog

By: Knetta Adkins

On August 2nd, I had the opportunity to meet with Secretary Xavier Becerra, the 25th Secretary of the Department of Health and Human Services. During his August trip to Georgia, Secretary Becerra hosted a roundtable with community leaders to hear about the health care concerns and challenges most affecting Georgians. Congresswomen Carolyn Bordeaux, Lucy McBath, and Nikema Williams, state Representative Matthew Wilson, and Mayor Keisha Lance Bottoms participated in the roundtable, as well as representatives from Community Catalyst, Protect Our Care Georgia, and others. It was an exciting moment to represent Georgians for a Healthy Future and share on behalf of the marginalized Georgians for whom we advocate. 

In June of this year, the Centers for Medicaid and Medicare Services (CMS) approved a change for Georgia’s Medicaid program that shifts how school nurses can bill for their services. Before June, Medicaid would only pay for school health services, including nursing services, if the student had a special education plan called an Individualized Education Program (IEP). IEPs are maps that lay out a program of tailored education instruction, supports, and services. These plans are required for all students receiving special education services like students with ADHD, autism, or a speech impairment. The approved change allows Medicaid to pay for more school health services provided to any student with Medicaid coverage.

Georgia consumers relieved of threat to health coverage by U.S. Supreme Court’s third affirmation that Affordable Care Act is lawful

With the ACA firmly in place as the law of the land, federal and state law makers should turn their attention to improving affordability and closing remaining coverage gaps

Statement by Whitney Griggs, Health Policy Analyst at Georgians for a Healthy Future regarding today’s ruling on the California v. Texas lawsuit by the Supreme Court of the United States. The lawsuit sought to invalidate the Patient Protection and Affordable Care Act; Georgia was a plaintiff in the case.

On June 3^rd, 2021, the Centers for Medicaid and Medicare Services (CMS) sent a letter to Governor Kemp requesting additional data on the potential impacts of the Georgia Access Model. The Georgia Access Model was put forward by Kemp in his 1332 private insurance waiver, and the model would end access to healthcare.gov for Georgia consumers.

CMS is requesting additional data from the state because they believe recent changes made by President Biden’s administration to the Affordable Care Act’s health insurance marketplace have made the state’s previous analysis outdated or inaccurate. The Biden administration’s changes include:  

• The COVID Special Enrollment Period (SEP)—through August 15, 2021, almost any American who does not have health insurance through their job can enroll in health coverage at healthcare.gov or by phone at 1-800-318-2596;
• More generous and expanded eligibility for Premium Tax Credits (PTCs)—almost anyone who qualifies for coverage through the ACA is now eligible for a discount on their monthly premium; and
• Increased funding for outreach and marketing for the ACA marketplace and enrollment opportunities.

These actions have led to more Americans, and Georgians, enrolling in Marketplace coverage. In addition, CMS believes that ACA enrollment would likely remain higher through 2023, when the Georgia Access Model is slated to begin.

In the letter, CMS also reasons the increase in enrollment could change insurance market dynamics enough to reduce the private sector’s incentive to enroll consumers. CMS believes with fewer uninsured people to enroll, the private sector may be less motivated to reach uninsured individuals. The idea that the private sector will be incentivized to enroll consumers once the competition of healthcare.gov is gone is a crucial assumption of Kemp’s waiver.

Georgia must now respond with updated data that takes into account the new federal changes. The new data will allow CMS to ensure the Georgia Access Model meets the protections specified in Section 1332 of the Affordable Care Act. These protections are:

1. Coverage must be at least as comprehensive as Marketplace coverage;
2. Coverage and protections against high costs must be as affordable as Marketplace coverage;
3. A similar number of people must have coverage under the waiver as without it; and
4. The waiver can’t add to the federal deficit.

The state may also request to adjust the Georgia Access Model, as needed, to meet waiver requirements in light of the new federal policies.

Once Georgia submits the new data about the Georgia Access Model, Georgia consumers, health advocates, and other stakeholders will have a chance to comment on the proposal again. CMS announced in their letter that they will hold a 30-day comment period after they receive Georgia’s new data. GHF expects the comment period will begin in early July. We will be working with our Cover Georgia partners to help Georgia individuals, organizations, and advocates comment. Stay tuned for your opportunity to weigh in again!

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.