ANDY MILLER, MHSE
CHIEF STRATEGY AND IMPACT OFFICER
As you have likely heard by now, Texas will be refiling with the Centers for Medicare and Medicaid Services (CMS) a request to extend the uncompensated care pool part of the Medicaid 1115 waiver for 10 years after the previously approved waiver was rescinded in April. This request will seek billions of dollars to continue reimbursing hospitals that incur costs due to uninsured patients, many utilizing emergency rooms for non-emergency conditions as they are required by law to treat anyone who presents for care. It has long been established that using the emergency room as the primary mechanism for providing health care is expensive, inefficient, and fails to enable people to get preventive services, medications, and effectively manage their chronic conditions.
Alternatively, expanding health insurance coverage in addition to adequate funding for safety net providers to cover uncompensated care costs for those who are not eligible for affordable insurance coverage could lead to both improved health outcomes for Texans and reduced costs to over time.
The state is holding a public comment period for stakeholder input before sending the application to CMS, which will then hold a second, federal public comment period prior to issuing its decision. CMS specifically cited the lack of a public comment period as its reasoning for rescinding Texas’s previous waiver extension. It is critical that Texans make their voices heard on this issue. The deadline to submit written comments is June 28, 2021.
For more information and to submit written comment, please visit the Texas HHS website.
Daniel Crowe, MD, FACP
TEXAS HEALTH INSTITUTE BOARD OF TRUSTEES
The coronavirus pandemic of 2020-2021 has had a profound impact on the mental health and well-being of Texans, as well as the rest of the US. The pandemic highlighted the need to revitalize the infrastructure of our public health system and to protect it from political influence at all levels. The trauma inflicted by the pandemic has touched all of us. Many have lost family members or friends. Other stresses include loss of employment, insurance coverage, housing, and access to healthcare. Children have lost more than a year of seeing their classmates and friends in person and have had to learn how to learn through a virtual school environment. Many small business owners lost their sole source of income due to restrictions required to minimize the spread of the virus.
The CDC reports that as a result of all of this, there has been a 27% increase in symptoms of anxiety and depression between April 2020 and February 2021. Emergency room visits due to overdoses and suicide attempts were up 36% and 26%, respectively. More than 87,000 Americans died of drug overdoses in the year ending in September 2020, representing a profound increase. Behavioral health service providers reported increased demand at the same time that they were decreasing staff sizes and closing clinics. Although the use of telehealth has risen dramatically, the effect on providing care for those with behavioral health and substance use disorders (SUD) has yet to be determined. The impact of the pandemic has disproportionately affected our communities of color. It has highlighted how a system that prioritizes a law enforcement and criminal justice approach to psychiatric crises often results in unnecessary injuries and deaths.
The health care community has responded rapidly to the new environment created by the pandemic. Some best practices have emerged:
There has also been a significant increase in enrollment in Medicaid and the Healthcare Exchange during the pandemic leading to many gaining or regaining access to health care.
As the public health institute of Texas, Texas Health Institute (THI) is committed to helping Texas overcome the trauma from the pandemic through their continued devotion to advancing the health of all Texans and their communities. THI’s dedicated staff continues to produce outstanding research and translational activities such as the recent work on health equity through the HOPE Initiative that is featured by the New England Journal of Medicine. THI works with the Texas Primary Care Consortium to integrate behavioral health into primary care practices throughout Texas. THI has been a leader in advancing collaborative action on chronic pain, SUD, obesity, oral health, genetic disorders and other topics important to Texans. To quote THI, “We strive to advance the health of all.”
Centering Equity in the COVID-19 Vaccine Rollout: Emerging Strategies for Reaching Communities of Color
Nadia Siddiqui, MPH
CHIEF HEALTH EQUITY OFFICER
April is National Minority Health Month, and this year’s theme sponsored by the HHS Office of Minority Health is #VaccineReady, underscoring the importance and urgency of vaccinating racial and ethnic minorities disproportionately impacted by COVID-19.
As seen across the nation and Texas, Black, Hispanic, and Indigenous populations have faced the brunt of cases, severe illness, death, and economic loss from the pandemic, yet they continue to have lower rates of receiving the COVID-19 vaccine. Local data shed further light into these realities. For example, a new report from the COVID-19 Modeling Consortium finds that areas across Austin with higher social vulnerability and rates of infection, such as the Eastern Crescent, have lower rates of vaccination. Similar gaps in vaccination rates by race and place have also been reported across Harris County, Dallas area, and other parts of the state.
Upending these inequities will require centering equity in the COVID-19 vaccine rollout. What that means is working to ensure the vaccine is accessible to all people—especially to those most at-risk, and not just to those with means to navigate the system. As the supply and availability of vaccines continues to increase, the objective is to work quickly, safely, and effectively to get as many shots in arms as possible, and to take explicit measures to simultaneously reach at-risk low-income and communities of color to minimize preventable infections, severe illness, and death. Doing so will require working authentically with communities and their trusted leaders and partners to learn their concerns, provide accurate and credible information, and access to the vaccination.
Lessons, promising strategies, and guidance are emerging on how to more equitably rollout the vaccine. Kaiser Family Foundation released a summary of promising state-level actions for addressing racial equity in COVID-19 vaccine efforts, and Johns Hopkins produced detailed guidance for working with communities of color to ensure equity in COVID-19 vaccination. Leading public health experts Dr. Faith Fletcher and Dr. Aletha Maybank recently penned 5 Ways to Make the Vaccine Rollout More Equitable, and Dr. Kingsley Okafor with Kaiser Permanente highlighted steps for getting to vaccine equity by addressing health equity. Our own work in the wake of the H1N1 pandemic 10 years ago with the HHS Office of Minority Health provides important guidance and steps on engaging communities of color in public health crises, also offering equity lessons from the H1N1 vaccination and response efforts.
Taken together, the following are highlights of what we have learned and what is emerging as strategies for ensuring all communities and people across Texas have access to information, resources, and the COVID-19 vaccine to be #VaccineReady.
Building Equity in COVID-19 Vaccine Outreach, Education and Communication
Work with trusted community partners to get to know communities, particularly in terms of the longstanding structural and social injustices that may serve as barriers to vaccine uptake—from the effects of systemic racism to the digital divide. See for example, our pre-pandemic survey work with community partners in Southwest Houston.
Identify and work with trusted community messengers for the vaccine to develop, test, and deliver clear, accurate, and culturally appropriate information in multiple languages. Trusted messengers and sources of information will vary by community and may include community and faith leaders, community health centers, ethnic media, and friends and family. In particular, partnerships with faith-based organizations are proving effective all across Texas, from El Paso to Fort Worth and the Rio Grande Valley.
Provide safe venues such as virtual townhalls or webinars for community members to interact with diverse experts they trust to share and have their concerns and questions answered in culturally and linguistically appropriate ways. See for example, NAACP’s Unmasked COVID-19 Town Hall Series, or Waco’s Spanish language virtual town hall.
Building Equity in COVID-19 Vaccine Access and Distribution
Prioritize vaccine distribution to ZIP codes most severely affected by COVID-19 and also facing greater social vulnerabilities, such as measured by the CDC Social Vulnerability Index. Harris County’s COVID-19 Vaccine Equity Strategy provides an example of prioritizing vaccine distribution to ZIP codes most severely affected.
Complement vaccination mega sites with targeted vaccination equity clinics and fairs in trusted community settings, such as community health centers, community clinics, mobile clinics, houses of worship, schools, social service sites and neighborhood centers. See for example the unique partnership between Baylor St. Luke’s and Texas Southern University to locate a vaccine site in the heart of the city’s historically Black Third Ward neighborhood.
Expand distribution to individuals facing mobility, transportation, or other barriers to reach homebound individuals. For example, Corpus Christi rolled out a promising initiative with the Fire Department and Meals on Wheels to reach homebound seniors, providing a statewide model. Austin is working to provide door-to-door COVID vaccines in east Austin neighborhoods.
Provide accessible hours of operation to vaccine clinics including after hours, late-night hours, and 24 hours.
Expand access points for registering beyond online, such as providing hotlines, call centers, and in-person registration through community and social service partners. Some localities are removing online registration altogether.
Hashtags: #VaccineReady #NMHM2021
Dr. Philip Huang, Director and Health Authority for the Dallas County Health and Human Services Department, recently spoke with Texas Health Institute about the continued need for preventive measures against COVID-19, current status of vaccination efforts, and what to expect moving forward in Texas.
Q: Why is it important for people to continue wearing masks in public at this stage of the pandemic, especially as millions of people have been immunized at this point?
A: It’s very encouraging all of the vaccination efforts that we’re having and the improvements in some of the indicators we are seeing, but it’s still too early to relax these measures. In Dallas County, as of March 24th, we’ve vaccinated over 532,000 persons, but that’s still only a fraction of the population. Approximately 26% of eligible persons have received one dose, and 13% have completed the full two doses, but that still leaves about three fourths of the population of adults who have haven’t received the vaccination. So there’s a significant percentage of the population that has not been vaccinated and it’s still very important for people to do the other preventive measures that we know are very effective.
Q: What is the optimal percentage of individuals that we would like to be vaccinated before we reach a place where we could see relaxation of masks and social distancing protocols?
The estimate that’s out there is 75-80% of the population need to be protected. That might include some that have had natural illness and protection, but we do not know how long that protection lasts. So, it’s really difficult to set an exact number on that, but the thought is 75-80% of people being protected. Ideally, [that would mean 75-80% vaccinated]. CDC released additional guidance regarding recommendations for people who are fully vaccinated, which, moving forward, provides some guidance and hope for what people can do safely after being fully vaccinated.
Q: If someone has been immunized, do they need to continue to wear masks and avoid crowded spaces where maintaining social distance isn't possible?
A: The new CDC guidance has some specific recommendations. When you are visiting with other fully vaccinated persons indoors, these people are within a single household and no one is at high risk for severe illness, then it is safe to not wear masks and not physically distance. However, if it’s with people from more than one household or persons that are at high risk for severe illness, then continue to practice masking and physical distancing. There is specific guidance in the new CDC recommendations. Also, in medium and larger public settings continue to practice masking and physical distancing. You still want to avoid crowds as much as you can.
Q: Now that there are several vaccine types available from different manufacturers, should people be concerned over which vaccine they receive?
A: All three of the vaccines that have been approved are really very effective. They have been almost 100% effective at preventing death and have very high effectiveness at preventing severe illness. There is still limited vaccine availability, so we strongly recommend that you take the first vaccine that becomes available to you. They are all very good vaccines. These [vaccines] are amazing scientific breakthroughs.
Q: What is one best piece of advice you would give to someone who continues to be concerned or confused about what preventative actions they should be taking?
A: I think we all want to get back to normal as soon as possible. We all want everyone to be able to receive the vaccine as quickly as possible, but we’re still not there yet. There’s still limits on the availability of the vaccine. There is still a large percentage of the population that is not vaccinated. Continue to do the preventive measures that we’ve been doing that have been very effective. We have shown that we can slow this down. Continue masking. Continue to avoid crowds. Continue to stay 6 feet physically distant. Continue to wash your hands. If you are fully vaccinated there are some settings where CDC has recognized it is very low risk and you can relax some of the guidance. But, in general it is still good to continue to be vigilant. We really want to slow this down. We are very concerned about these variants that are out there, the UK variant, South Africa, and Brazil, that have been shown to be able to be spread more easily and may have some resistance to the vaccine. Although, still thus far it is showing there is efficacy from the vaccine. But these genetic variances, and other variables out there make it clear we need to continue to be vigilant.
Q: Any closing thoughts or additional comments you would like to add?
A: We are all very excited about the availability of vaccines. We’re doing everything we can to get everyone vaccinated as quickly as possible. We would love for everyone to be priority. Unfortunately, right now there is still limited vaccine availability, but hopefully that will be changing over the short term with more vaccines becoming available. Let’s keep doing the common sense preventive measures and not let up because it would be very easy that we could see some backsliding on this if we let our guard down.
Philip Huang, MD, MPH
Dr. Huang has been the Director and Health Authority for the Dallas County Health and Human Services Department since February 2019. Prior to this he had served as Medical Director and Health Authority for the Austin Public Health Department, and as Chief of the Bureau of Chronic Disease & Tobacco Prevention at the Texas Department of State Health Services. He received his undergraduate degree in Civil Engineering from Rice University, his MD from the University of Texas Southwestern Medical School, and his Master's in Public Health from Harvard with a concentration in Health Policy and Management. While at Harvard, he led the successful movement to divest of their tobacco stocks. Dr. Huang completed his residency training in Family Medicine at Brackenridge Hospital in Austin, and served two years as an Epidemic Intelligence Service (EIS) officer with the Centers for Disease Control and Prevention assigned to the Illinois Department of Public Health where he conducted epidemiologic studies in chronic disease and infectious disease outbreak investigations. He is currently an Assistant Professor with the University of Texas at Austin, Dell Medical School, and an Adjunct Assistant Professor with the University of Texas School of Public Health, Austin Campus. He has served as Principal Investigator for numerous CDC and State-funded public health cooperative agreements.
Kenneth D. Smith, Ph.D.
SENIOR HEALTH POLICY RESEARCH ANALYST
Translating evidence and ideas, or “sense-making,” is a core competency of Texas Health Institute (THI) as the state’s public health institute. The Community Health team’s work over multiple projects in East Texas uncovered trends occurring regionally. That work offers a case study of how THI has strengthened local partnerships for collaborative impact at the regional level.
THI conducts community health needs assessments (CHNA) throughout the state. Two years ago, we conducted CHNAs for four of CHRISTUS Health System’s integrated health care delivery facilities in East Texas (read more here).
Although we used the same approach, each CHNA was a separate product informed by local data, including the voice of the local community. Despite that, we observed similar patterns across health systems. Each health system identified at least one social determinant of health need, and all identified mental and behavioral health as a top priority.
Our CHNA work provided invaluable perspective for the East Texas Local Government Expenditures Project which focused on Harrison and Angelina Counties and their respective capital cities. Our CHNA for CHRISTUS Good Shepherd covered Harrison County, but we were also familiar with CHI St Luke’s CHNA for Angelina County which, incidentally, identified access to behavioral health as the second highest priority in the county. The project was a collaborative effort with the Stephen F. Austin University (SFA) School of Social Work who recruited informants and conducted interviews and was funded by Episcopal Health Foundation. Authorized by the county and municipal legislators and executives, the project was designed to support recommendations to improve community health based on an analysis of budget spending trends over 10 years as well as informant interviews with officials familiar with the budget process. Although unexpected, the need to address behavioral health arose as a research finding.
Study interviewees from the two counties described the interaction between homelessness, substance abuse, co-occurring mental health conditions, and the criminal justice system. They painted a picture that researchers have observed across the country. This includes prior unrelated SFA research documenting the vicious cycle of substance abuse, prison time, and homelessness operating across rural counties in East Texas.
Recommendations offered by Harrison County interviewees suggested the need for a community-led effort to address these complex issues from a systems and regional perspective. This was the rationale for THI to partner again with SFA to respond to HRSA’s Rural Communities Opioid Response Program—Planning (RCORP) opportunity. The Panola-Gregg-Harrison Community Initiative to Address Substance Misuse is the result of our successful HRSA proposal. The initiative involves a regional gap analysis and community action plan to address prevention, treatment, and recovery from opioid and methamphetamine misuse in the targeted rural community.
The partnership with SFA creates synergies that ensure that we have a trusted local partner grounded in the community as we work regionally. THI is the convenor for the consortium responsible for implementing the community action plan.
This work emerged as a result of working with local stakeholders while seeing the big picture and seizing opportunities for collaborative action. It exemplifies the kind of regional work for which state public health institutes like THI are uniquely suitable.