Federal Policy Changes Research Articles

Insights from Washington State's COVID-19 Response: A Mixed-Methods Evaluation of WIC Remote Services and Expanded Food Options Using the RE-AIM Framework.

BackgroundIn response to the COVID-19 pandemic, Washington State’s Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without using federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores.ObjectiveThis study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and challenges involved in their implementation; and considerations for their continuation in the future.DesignA mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and participants, and quantitative programmatic data from WIC agencies across the state.Participants/settingThis study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021). The research team collected data and conducted analyses between January 2021 and August 2021.AnalysisAn inductive thematic analysis approach with Dedoose software was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates.ResultsAll WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality.ConclusionsParticipation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change, and others could be implemented under existing federal regulations.

EP507: Patients’ reasons for genetic testing refusal in cancer evaluations: An analysis of the literature and opportunities to educate

eP507: Patients’ reasons for genetic testing refusal in cancer evaluations: An analysis of the literature and opportunities to educate

Health Insurance Literacy Levels of Information Intermediaries: How Prepared Are They to Address the Growing Health Insurance Access Needs of Consumers?

Background:With rising unemployment rates brought on by coronavirus disease 2019 pandemic, the rates of underinsured and uninsured consumers are likely to rise. Health information intermediaries play a critical role in assisting consumers with navigating the complexities of the United States health care system and the ever-changing health care policy landscape. Not much is known about the health insurance literacy (HIL) levels of information intermediaries and their ability to assist consumers with making informed decisions about their health insurance.Objective:This study aimed to examine the association between information intermediary levels of HIL, sociodemographic factors, and confidence and behaviors in assisting consumers with health insurance needs.Methods:We surveyed 118 information intermediaries from various roles to assess objective and subjective HIL, frequency, and confidence in assisting consumers, and confidence in understanding changes in federal health reform policies and state Medicaid waiver programs.Key Results:Less than one-half (39%) of information intermediaries had high subjective HIL and much fewer (13%) had high objective HIL. The average frequency of assisting consumers with health insurance scores were somewhat low, and confidence in assisting consumers with health insurance scores and confidence with understanding state and federal policies were modest. Results from our logistic regression model indicated that confidence in assisting consumers was found to be the only significant contributor to high subjective HIL. For every one-point increase on the confidence assisting subscale, there was a 35% increase in the information intermediaries having high subjective HIL.Conclusions:Findings from this study, coupled with rising uninsured rates, indicate the need for tailored training programs and resources to equip our information intermediaries to provide timely and appropriate health insurance support for consumers. [HLRP: Health Literacy Research and Practice. 2022;6(1):e30–e36.]Plain Language Summary:In a sample of 118 information intermediaries, representing community health workers, navigators, and other people in outreach roles, the majority had low subjective and objective HIL. We also found that as confidence with assisting consumers with health insurance needs increases, HIL increased as well. These findings indicate that tailored training programs and resources are needed to equip information intermediaries to provide health insurance support for consumers.

State-level response to gabapentin misuse in the United States: Implications and future direction

Abstract Purpose Gabapentin misuse is on the rise and has forced many US states to mobilize policies to address this public health concern. The purpose of this manuscript is to update state-level gabapentin misuse–related policies in the US through September 1, 2021, discuss the benefits and risks of current measures, and highlight gaps in national response. Methods Identification of state and federal district policy changes and deliberations related to gabapentin were searched via internet for all 50 states and 1 federal district (n = 51). Only results from state regulatory bodies, such as the board of pharmacy, or state legislative bodies, such as the senate, were considered for inclusion. Results Results showed that 22 states and federal districts (43.1%) tightened regulation, while another 2 (3.9%) are considering doing so. Of the 22 states and federal districts with policy changes, 15 (68.2%) enrolled gabapentin into their prescription drug monitoring program, while 7 (31.8%) reclassified gabapentin as a Schedule V controlled substance (C-V). Conclusion Absent of federal guidance surrounding gabapentin misuse, the onus has fallen on individual states; thus, approaches have ranged from no intervention to reclassification as a C-V. These measures aim to reduce medication supply but fall short of addressing patient outcomes and reducing harm. Therefore, harm reduction–informed public health policies must be implemented to positively impact patient outcomes and enhance safety.

Community college responses to align career and technical education programs with changing labor markets

AbstractA new wave of federal legislation is drastically affecting how community colleges create and deliver programs in career and technical education (CTE). A key focus area shared by these federal policy changes is program‐to‐labor market alignment in which community colleges must utilize local labor market data to tailor their CTE programs to meet the needs of local businesses and industry. This article presents an overview of the rapidly shifting economic and policy environments, and offers three exemplars of community colleges in rural, suburban, and urban service areas that have successfully aligned CTE programs with local labor market demand. In all, this article highlights innovations and best‐practices offered by these exemplars as the federal government makes alignment a top priority for the 21st century community college.

Addressing social determinants of health in pediatric health systems: balancing mission and financial sustainability.

With increasing recognition of the impact of poverty, racism and other social factors on child health, many pediatric health systems are undertaking interventions to address Social Determinants of Health (SDoH). This review summarizes these initiatives and recent developments in state and federal health policy impacting funding for these efforts. Although the evidence defining optimal approaches to identifying and mitigating SDoH in children is still evolving, pediatric health systems are making significant investments in different initiatives to address SDoH. With limited reimbursement available through traditional payment streams, pediatric health systems and Accountable Care Organizations are looking to value-based payments to help fund these interventions. Federal and state policy changes, including use of Medicaid funds for nonmedical interventions and introduction of the Accountable Health Communities model to pediatrics, offer additional funding sources to address SDoH. Initiatives among mission-driven pediatric health systems to address SDoH are increasingly common despite funding challenges. Value-based payments, expansion of Medicaid funding resulting from policy changes and delivery system reform, along with health system philanthropy and operating revenues, will all be needed to meet mission-based goals of addressing SDoH while supporting financial sustainability.

Energy policy and coastal water quality: An integrated energy, air and water quality modeling approach

Federal policy changes in the management of carbon emissions from power plants offer a potent real-world example for examining air-land-water interactions and their implications for coastal water quality. We integrate models of energy (Integrated Planning Model (IPM)), air quality (Community Multiscale Air Quality (CMAQ) and water quality (SPAtially Referenced Regression On Watershed attributes (SPARROW)) to investigate the potential water quality impacts of policy-driven changes in total nitrogen deposition in watersheds draining to US coastal areas. We estimate the combined effects of three recently proposed energy policy scenarios, population growth, and climate change. We decompose the combined effects into the roles of the individual components on the supply of riverine nitrogen for the entire US and eight coastal regions. We find that population growth is the most important driver of changes in coastal nitrogen flux. Energy policies play a minor role in offsetting the negative effects of population growth, although the effect varies by energy policy and region. The greatest population and policy effects are projected for the Gulf of Mexico. Given limited reductions in nitrogen emissions and deposition associated with energy policies, the net effect of policy and population changes is an increase in total nitrogen flux to all estuaries relative to the 2010 baseline. While population growth increases flux, and energy policies decrease flux in all regions, climate change can either increase or decrease flux depending on the region. That is because the relatively large individual effects of temperature and precipitation on watershed nitrogen processes work in opposing directions. The net result of the offsetting nature of individual climate processes varies in both magnitude and direction by coastal region. Further research is needed to sort out individual temperature and precipitation effects in different regions.

Ending Child Poverty by Investing in Children and Families.

Ending Child Poverty by Investing in Children and Families.

Trends in Health Insurance Among Cancer Patients Receiving Radiation Therapy From 2008-2017

In 2010, the Affordable Care Act (ACA) was enacted, which allowed for increased access to health insurance in the US. Since then, there was a decrease in uninsured patients including those with cancer receiving radiation therapy. In 2017, federal policy was changed in regards to the ACA including a shortened enrollment period and significantly reduced funding. We aimed to determine trends in rates of uninsured patients receiving radiation therapy within this time period in order to identify correlations of these policy changes.We obtained data from the National Cancer Database (NCDB) Public Benchmark Reports from 2008-2017 to investigate trends in uninsured cancer patients who received radiation therapy. This data was stratified by all patients who received radiation therapy, and calculated percentages of those without insurance from the years 2008 to 2017. We then identified trends of uninsured status by race including White, Black, Hispanic, Asian/Pacific, Native American, and unknown.According to the data, the percentage of patients receiving any kind of radiotherapy without health insurance declined over the years of 2008 to 2016 (2.3% to 1.76%). In 2017, the trend reversed with 1.78% of patients without health insurance. The percentage of patients who were uninsured that identified as White was lower than the entire population, and also declined from 2008 to 2016 (1.73% to 1.12%). In 2017, the trend reversed to 1.18%. The percentage of patients who were uninsured that identified as Black was higher than the entire population, but also declined from 2008 to 2016 (4.2% to 2.92%). In 2017, this trend continued to decline to 2.69%. The percentage of patients who were uninsured that identified as Hispanic was the highest of any group at any year. This group had an initial increase in uninsured patients from 2008 to 2012 (7.35% to 10%), then decrease by 2016 (7.78%). By 2017, this trend reversed again with 8% of the Hispanic population to be reported as uninsured.In the last decade, there has been an overall trend towards less uninsured patients receiving radiation therapy in the United States, with the exception of 2017, which saw a slight increase, disproportionately affecting the Hispanic population. While it is uncertain as to whether federal policy changes in the promotion and administration of ACA affected these trends, this data mirrors observations in other series looking at un-insurance in cancer survivors. Further work is indicated to determine if this trend continues throughout the remainder of the past federal administration. In the meantime, it is essential to acknowledge the continued racial health disparities increase efforts in making access to cancer care more equitable.

Concerns and Anxieties of Patients During Hospitalization for COVID-19.

ObjectiveThe objective of this study was to evaluate the concerns and anxieties of hospitalized coronavirus disease (COVID-19) patients.MethodsA questionnaire was distributed to patients on discharge. The responses were analyzed once they were returned by mail.ResultsResponses were received from 27 of 39 patients (average age, 50 ± 17 years). Among the participants, 16 were male (59.3%), 19 were symptomatic (70.4%), and two required a ventilator (7.4%). Anxiety about symptom exacerbation was reported by 36.0% of participants. Quarantine-associated stress was experienced by 60.0% of participants, and 72.0% of participants supported the change in federal policy that allows asymptomatic patients and patients with mild conditions to isolate themselves at a hotel or their home. Following discharge, 44.0% of participants experienced anxieties regarding their lives after discharge, and 56.0% were anxious regarding discrimination and rumors. During hospitalization, 68.0% of participants re-evaluated their attitude toward health, 44.0% regretted the preventative measures they took before contracting COVID-19, and 44.0% felt guilty for becoming infected.ConclusionsParticipants experienced various kinds of stress related to hospitalization for COVID-19. There was a trend of people being more concerned about their relationships than their own health. Therefore, as asymptomatic participants and participants with mild symptoms also experienced psychological stresses, it is also necessary to consider the psychological and social effects of the disease.

“We Have to Meet Those Clients Where They're at” ‐ Michigan Behavioral Health Providers' Responses to Telehealth Policy Changes during COVID‐19

Research ObjectiveTo understand the impact of state and federal policy changes during the COVID‐19 pandemic on use and effectiveness of telebehavioral health based on provider experience,Study DesignBetween July and August 2020, researchers conducted one‐hour interviews with 31 Michigan‐based behavioral health providers from 15 counties. These semi‐structured interviews included the following topics: (1) Experience with telebehavioral health prior to, and during, the pandemic, (2) Changes in cost of, access to, and quality of care between in‐person and telebehavioral health services, and (3) Telebehavioral health's impact on providers and clients. The interviews were recorded, transcribed, and later analyzed with Dedoose™ software to identify common themes between responses.Population StudiedInterviewees included a psychiatrist, psychologists, registered nurses, clinical social workers, mental health counselors, substance use disorder counselors, applied behavior analysts, and peer support specialists.Principal FindingsTelebehavioral health provision increased during the pandemic, with all interviewees reporting providing telebehavioral health services ‐ 19 for the first time. All interviewees agreed that newly‐enacted state and federal policies made it legally and financially viable to continue safely providing services during the pandemic. Fourteen interviewees reported increased job satisfaction and decreased feelings of burnout. No interviewees reported a breach of health data as a result of using non‐public facing audio‐visual communications. Overall, interviewees agreed telebehavioral health services were at least as effective as in‐person services. Clients with certain conditions (social anxiety, post‐traumatic stress disorder) seemed to respond better to telebehavioral health services. Clients with other conditions (substance use disorder, developmental disabilities) responded less favorably.Thirty interviewees reported clients were satisfied with telebehavioral health services, with some clients preferring them over in‐person services. Twenty‐eight reported telebehavioral health reduced or removed barriers that would have otherwise prevented these clients from receiving care, such as the need to arrange for transportation, childcare, or time off from work. This resulted in decreased no‐show rates and more regular contact between providers and clients. Access to care for geographically isolated populations increased when audio‐only telebehavioral health was authorized; these populations used to have to travel further for care, and often lacked high‐speed internet and internet‐connected devices necessary for audio‐visual telehealth services.ConclusionsDespite telebehavioral health's effectiveness and widespread client approval, interviewees expressed that their current work with telehealth was only possible because of recent policy changes. Should those policies revert back, providers may not be able to continue to provide these services. For some clients, such as those who are geographically isolated and unable to engage with anything but audio‐only telehealth, reverting these policies would mean notable barriers and/or losing access to care entirely.Implications for Policy or PracticeIn Michigan, policy implications for both private and public insurances include continuing audio‐only telehealth authorization and improving coverage of telebehavioral health by instituting service and reimbursement parity policies. Such policies could be enacted through Medicaid plan amendments or amendments to Michigan's Insurance Code. For federal policymakers, implications include amending HIPAA to improve acceptability of non‐public facing audio‐visual communications and extending certain provisions of the CARES Act, such as allowing audio‐only telehealth as a modality of last resort, through new laws and regulations.Primary Funding SourceInstitute for Healthcare Policy and Innovation.

Reforming the health care system to address structural racism

Reforming the health care system to address structural racism

The White Supremacy Hydra

Fundamentally, the so-called “child welfare system”—more appropriately named, the family regulation system—is a policing system rooted in white supremacist ideologies and techniques. From its earliest iteration, the family regulation system has functioned to pathologize, control, and punish the families entrapped in its web, most especially Black families. Nevertheless, among many, the myth persists that the family regulation system is one of child protection and family support. This is especially true when discussing the Family First Prevention Services Act of 2018, which—for the first time since the establishment of the modern family regulation system—opens up federal funding streams previously reserved for the removal of children to the foster system to provide prevention services for families in which children have not yet been removed to the foster system. While the Act is a course change in federal family regulation policy, this Article traces how it leaves undisturbed the pathology, control, and punishment central to the policies that preceded it.

The lived experience of medical training and emotional intelligence

The shifting health care landscape in the United States has surfaced challenges related to increased accountability, interprofessional health care teams, and changes in federal policy—all of which compel physicians to adopt roles beyond clinician such as clinical investigator, team leader, and manager. To address these challenges, leadership development programs across the continuum of medical education aim to develop critical leadership skills and competencies, such as emotional intelligence. Such skills and competencies are largely taught through didactic approaches (e.g., classroom). These approaches often neglect the context of learning. From medical residency to a hospital or clinic, the contextual lived experience is habitually overlooked as a vehicle for developing emotional intelligence. This article highlights lived experience, such as medical residency, as an approach to develop emotional intelligence. First, we address the need for developing emotional intelligence as a leadership skill as well as the suitability of medical residency for such development. Next, we discuss the background of lived experience and emotional intelligence. Lastly, we identify future directions for leveraging lived experiences of medical residency to develop emotional intelligence.

How Federal Policy Changes Can Advance the American Heart Association's Mission to Achieve Health Equity.

How Federal Policy Changes Can Advance the American Heart Association's Mission to Achieve Health Equity.

The new services that opioid treatment programs have adopted in response to COVID-19

COVID-19 has exacerbated the opioid epidemic and transformed how programs treat opioid use disorder. In response to the pandemic, the federal government modified guidelines to allow opioid treatment programs (OTPs) greater flexibility in the provision of medication for opioid use disorder. We conducted a telephone survey of 31.10% of OTPs in the contiguous United States between June and July 2020. We contacted a random sample of 477 facilities and obtained responses from 373. The survey asked questions about new patient intake, screening for COVID-19, social distancing measures, as well as new treatments offered due to changes in federal government policy. We calculated percentages of positive and nonpositive responses to each survey question. We estimated logistic regressions of facility-, county- and state-level predictors of each treatment approach. Most OTPs are taking new patients (91%). Roughly 83% of them screen for COVID-19 symptoms for in-person visits and about 92% use social distancing measures. More than half of OTPs provide curbside treatment (83%) or telehealth (81%). Less than a quarter of OTPs offer medication drop off (21%) or pick up by a trusted person (32%) when patients need to quarantine due to COVID-19. Results from multivariable logistic regressions show that OTPs in states that had a shelter-in-place policy are more likely to socially distance for in-person visits than those in states without such a policy.

Better Diet Quality in the Healthy Hunger-Free Kids Act and WIC Package Reduced Childhood Obesity.

* Abbreviations: HEI 2010 — : Healthy Eating Index 2010 HHFKA — : Healthy, Hunger-Free Kids Act WIC — : Special Supplemental Nutrition Program for Women, Infants, and Children The reductions in the prevalence of childhood obesity achieved by the Healthy, Hunger-Free Kids Act (HHFKA) and the changes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package have not been widely recognized. Both the HHFKA and the regulatory updates to the WIC package substantially changed the quality of the foods provided. Both changes improved diets and led to reductions in the prevalence of obesity in the most vulnerable youth served by these programs. The HHFKA was passed by Congress in 2010, and its implementation was required in schools by 2012. In the Act, Congress set age-appropriate caloric ranges, required that at least 51% of grains be whole grains, required students to take at least one-half cup serving of fruits or vegetables with every school breakfast or lunch, and required that schools offer 1 cup of flavored or unflavored fat-free milk or 1% milk. Despite concerns, the changes were not associated with an increase in plate waste.1 In several studies, researchers have confirmed an increase in the quality of school meals and in improved consumption. For example, dietary quality was assessed before and after implementation of the new HHFKA standards by using the Healthy Eating Index 2010 (HEI 2010) and food consumption data from the nationally representative NHANES.2 The HEI 2010 score reflected the degree to which dietary intake was consistent with the 2010 Dietary Guidelines for Americans. The HEI 2010 scores among students aged 5 to 18 years were stratified by low-income, low-middle–income, and middle-high–income students and compared to those among non–school lunch participants in the same income categories. The HEI 2010 scores increased from 42.7 to 54.6 among school lunch participants compared to a decrease from 34.8 to 34.1 among nonparticipants. The differences in comparison with non–school lunch participants were 12.6, … Address correspondence to William H. Dietz, MD, PhD, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, 214 11th St NE, Washington, DC 20002. E-mail: dietzwcd4{at}gmail.com

Telemental health policies for college students during COVID-19

Federal and institutional policy changes have accelerated the use of telemental health to care for college students distant from their mental health providers during the early part of the COVID-19 pandemic. Temporary measures have made telemental health more readily available, including relaxing of regulations related to interstate licensure, controlled substance prescribing, patient privacy, and reimbursement. Though early efforts are underway to sustain these changes during and in the wake of the pandemic, there are important areas in which federal and institutional policy are still lacking. Additional steps are needed to successfully implement and sustain telemental health for college students include ensuring student access to technology and Internet; proactive outreach to optimize the student’s home environment, addressing concerns about safety and confidentiality; developing the means to track rapidly shifting telemental health policy changes; and developing centralized resources that enable remote providers to become familiar with involuntary commitment laws and emergency protocols.

The political economy of drug and alcohol regulation during the COVID‐19 pandemic

States tightly regulate access to alcohol and other substances. During the pandemic and related state of emergency, state and federal governments adopted a variety of regulations affecting this access. State shelter‐in‐place orders included decisions about whether liquor stores and marijuana dispensaries are essential businesses. Decisions about telehealth access to medical marijuana or treatments for substance use disorders were made at the state and federal levels. This article examines the political economy behind these decisions, focusing on deviations from the norm including Pennsylvania's decision to close state‐run liquor stores. Interest groups and other political considerations help explain state and federal policy changes affecting access to alcohol and other substances.

Reduction in Oregon's Medication Dosing Visits After the SARS-CoV-2 Relaxation of Restrictions on Take-home Medication.

To slow the spread of SARS-CoV-2 in opioid treatment programs (OTPs), SAMHSA notified State Opioid Treatment Authorities that stable patients could receive up to 27 days of take-homes, less stable patients could receive up to 13 days with fewer take-homes for other patients. An analysis assessed how the relaxed standards affected the number of patient dosing visits and the amount of take-home medications dispensed in Oregon's 20 public, nonprofit, and for-profit OTPs.OTPs reported the number of patients receiving take homes pre and post federal policy change at 3 time points: pre SARS-CoV-2 (February or first half of March), post 1 SARS-CoV-2 (March, April, or May), and post 2 SARS-CoV-2 (April, May, or June). The patients receiving each quantity of take-homes were counted and means calculated for visits and take-homes per patient per month. A negative binomial mixed-effects regression model assessed change in mean dosing visits per patient.During the pre SARS-CoV-2 period, OTPs served 7792 patients monthly with 120,513 medication visits and dispensed 44,883 take-home doses. Mean patient visits per month were 15.5 with 5.8 take-homes per patient per month. Following the policy change, medication visits declined 33% and take-home medication increased 97% with 10.4 mean visits per patient and 11.3 mean take-homes per patient. The negative binomial mixed-effects regression model estimated a 54% reduction in mean visits per patient. The policy change had the intended effect. More research is needed to assess unintended consequences associated with increased access to take-home medication.