Trend 2: Health Care Delivery System
The COVID-19 pandemic severely strained the health care system and required front-line workers to take on more, both physically and mentally, to respond to the crisis as their colleagues quarantined, contracted COVID-19, or were unable to work due to being high-risk or having caretaker responsibilities at home. Each part of the health care system continues to face a unique set of issues that are likely to have effects beyond the pandemic, including:
- Hospitals: The American Hospital Association estimates that the pandemic cost U.S. hospitals and health systems $202.6 billion between March 1st and June 30th in 2020, due to decreased utilization, increased costs, and staffing challenges.7 Congress allocated COVID-19 relief funds to hospitals, but facilities with larger portions of privately insured patients and high pre-pandemic operating margins received a greater portion of those funds.8 This left rural hospitals and similar facilities with less access to this critical funding, due to their focus on serving Medicare and Medicaid populations and overall lower patient volume. These facilities entered the pandemic with already thin margins, workforce shortages, and challenging dynamics serving their communities due to geographic isolation.9 The added pressure from the pandemic has the potential to further increase consolidation or spur additional closures, leading to a decline in the number of rural hospitals and other similar facilities further exacerbating the issue of access to care for those populations they serve.
- Federally Qualified Health Centers (FQHCs): FQHCs serve over 30 million Americans, including 1 out of every 5 Medicaid members.10 The two leading challenges these providers reported facing prior to the pandemic were financial solvency and workforce shortages. Both were exacerbated by the pandemic due to revenue decreases, site closures (particularly dental and school-based clinics), and staffing challenges.11 Even with increased capacity due to expansion of telehealth, these challenges are likely to continue throughout 2021 as FQHCs work to balance the continued resource demands associated with COVID-19 testing, vaccine distribution, and on-going patient care. Communities served by FQHCs could experience access issues beyond the pandemic depending on the federal and state supports provided to FQHCs to help address these current and increasing challenges.
- Long-Term Care Facilities: Nursing homes and other long-term care facility residents and staff have been disproportionally affected by COVID-19. Nationally, 6% of all cases and 38% of deaths from the virus are associated with long-term care settings.12 While this created greater demand for in-home care services, the pent-up demand for rehabilitation services along with the aging U.S. population continue to drive demand for facility-based services. Prior to the pandemic, facilities faced workforce shortages due to low wages and limited benefits. Those shortages have been compounded by the pandemic as long-term care facilities continue to lose staff (7.8% of employees since February 2020) even as overall health care employment rebounds.13
Trend 3: Health at Home
The COVID-19 PHE changed the landscape of health care delivery and utilization in many ways. From the beginning of the pandemic, individuals were encouraged to stay at home; both to minimize risk of disease exposure and to ensure that vital health care resources remained available for individuals battling COVID-19. This initially led to a decrease in preventive and elective health care services, ambulatory care utilization and hospital admissions.14 The shift in care delivery presented an opportunity to leverage existing capabilities and innovative technology to deliver health care to individuals at home. Additionally, the disproportionate impact of COVID-19 on nursing homes highlighted the vulnerability of individuals living and working in congregate, institutional settings and put renewed focus on long-term care delivery. States were able to leverage emergency flexibilities to support existing Home and Community-Based Services (HCBS) and long-term services and supports (LTSS) infrastructure and increase access to telehealth.15 After the PHE ends, state and federal policymakers need to assess which, if any, of the changes should be permanently adopted.
Flexibilities Allowed During PHE
HCBS Waiver Flexibility
As of March 2021, all 50 states and the District of Columbia had at least one 1915 (c) Appendix K waiver approved by CMS.16 An Appendix K is a standalone appendix used to amend a specific waiver, multiple approved waivers, or all approved waivers in a state. CMS created a specific Appendix K template for the COVID-19 PHE to help states quickly identify available flexibilities and streamline the approval process. The template gave states the option to modify policies related to access and eligibility, expand covered services, and support financial stability for existing HCBS workforce via retainer payments.
Provider and Service Delivery Flexibility
With a greater number of individuals needing health care delivered at home, states looked for opportunities to leverage existing family caregivers, flex providers where they were most needed, and support the already stretched HCBS workforce. Once the PHE was declared, states were able to submit Section 1135 waivers to amend certain requirements related to Medicare, Medicaid, and the State Children’s Health Insurance Program (CHIP). CMS also released a template for State Plan Amendments (SPAs) to address changes related to the PHE. These tools gave states the opportunity to adapt provider requirements in a variety of ways to rapidly improve access to health care at home. All 50 states plus the District of Columbia leveraged Section 1135 waivers to allow out-ofstate providers with equivalent licensing in another state to provide care. Some states expanded the workforce by allowing family members or member representatives to deliver personal care services. Other states sought to increase the payment rate for personal care attendants or expand the provider types that can order, certify, and recertify member’s home health care plans.17 Equally important as expanding the pool of providers was allowing reimbursement for services delivered in the home. For example, 30 states used Section 1135 waivers to allow HCBS services to be delivered in settings that did not meet traditional HCBS settings criteria.
Telehealth is one of the key tools leveraged during the PHE to address health care needs. CMS released a State Medicaid & CHIP Telehealth Toolkit in April of 2020, which identified key areas of telehealth for state consideration.18 Flexibilities included allowing traditional telephone calls as qualifying technological modalities, expanding the originating sites (patient location) eligible to utilize telehealth, adjusting payment rates for services, and expanding the types of services allowed to be delivered via telehealth.
Flexibilities Allowed Post-PHE
As part of post-PHE program design conversations, there is already a focus on allowing, in some capacity, the continued expansion of covered telehealth benefits and flexibilities leveraging HCBS. Additional research is warranted to ensure delivery of high-quality care and safeguards against fraud, waste, and abuse.
Trend 4: Role of Public Health in Health Care
Public health funding has faced funding cuts at the state and local level by 16% and 18% respectively since 2010.19 As a result of these continued cuts, health departments have dealt with reduced capacity and availability of resources, including a diminished workforce, which were then exacerbated by additional budget and resource constraints due to the COVID-19 pandemic. These underlying challenges within the public health support system and infrastructure contributed to the nation’s initially limited ability to respond effectively to the global pandemic. In order to effectively address ongoing and emerging public health threats, the capacity shortages magnified by the COVID-19 pandemic will need to be addressed. The health care system can be a partner in supporting many of these efforts.