On September 19, 2023, the Department of Health and Human Services (HHS) Office of Intergovernmental and External Affairs (IEA) held a briefing on COVID-19 Vaccine Updates. This call was led by Secretary Xavier Becerra and included updates from the Director of the Centers for Disease Control and Prevention (CDC), Dr. Mandy Cohen, and the Director of the Center for Biologics Evaluation and Research (CBER) at the Food and Drug Administration (FDA), Dr. Peter Marks, on the new COVID vaccine, CDC’s Bridge Access Program which provides no-cost COVID-19 vaccines, ongoing mitigation measures, and Strategic National Stockpile (SNS).

Vaccine Recommended as Best Measure Against Long COVID

Currently, there is an underlying immunity due to 97% of people across the United States either having been vaccinated or had COVID previously. However, based on data it, appears that this protection decreases over time. The most protection is provided in the first 4-6 months after receiving the vaccine, and it can take up to two weeks for your immune system to build up the immunity needed to fight off the virus.

The CDC is concerned as we are still seeing hundreds of people die every week, with people over 65 at the highest risk for negative outcomes. Secretary Beccera highlighted the need for assistance from the public because people are dying in numbers we weren’t seeing as recently as a month ago. Regarding long COVID, the CDC shared there is still much to be learned. In the meantime, the recommendation continues to be to receive the vaccine as it’s the best way to reduce any risk of getting long COVID. Both the CDC and FDA recommend that everyone over the age of 6 months receive not only the updated COVID vaccine, but the flu and RSV (Respiratory Syncytial Virus) vaccines as well.  Dr. Cohen mentioned that the Maternal RSV vaccine will be available soon, specifically for expecting mothers which, as of September 22, is officially recommended by the CDC. There is a strong emphasis from HHS, CDC, and the FDA to get vaccinated as this is the first time we have ever had immunizations for all three major respiratory viruses.

Updated COVID Vaccine Available at No-Cost through Bridge Access Program

The FDA has approved a new COVID vaccine, updated to match the strain that is currently circulating. The FDA recommendation is for those ages 5 years and older to receive a single dose, regardless of whether an individual has previously been vaccinated. For ages 6 months to 4 years, children are eligible to receive two doses of either Moderna or Pfizer. An important note for the immunocompromised is that a second or additional vaccine may be necessary. If someone currently has COVID but wants to receive the new vaccine, it is recommended to wait two months from the time since having COVID or receiving a previous vaccination. Dr. Marks reiterated confidence in the safety and effectiveness of these updated vaccines, while recognizing they may need to be updated on an annual basis, similar to what is done for the seasonal influenza vaccine.

Even though we are outside of the Public Health Emergency (PHE), Dr. Cohen emphasized that the updated COVID vaccine will still be available for free. This is either through insurance or through the CDC’s Bridge Access Program for those uninsured or underinsured where vaccines can be received at pharmacies such as CVS or Walgreens. Follow this link to find sites where free vaccines can be obtained, as well as additional resources. Secretary Beccera explained that this bridge program has received substantial funding from HHS, and that HHS has been in contact with private plans, as well as Medicaid and Medicare, so that there are no issues with receiving the vaccine at no cost.

Other COVID Related Updates

HHS’ Project NextGen will begin working with scientists to explore what next steps may be necessary to continue combatting the spread of the virus. Related to this, Secretary Beccera gave an update on the Strategic National Stockpile (SNS), which is a resource to supplement state and local supplies during public health emergencies. It can be utilized as a short-term buffer when the supply of these materials is not immediately available or is not sufficient to match immediate need. Currently, the SNS is being prepared so that there isn’t an emergency situation where there aren’t enough masks, vaccines, or tests available. Secretary Becerra explained that they have learned from the pandemic as to what they need to do to be prepared, especially in addressing supply chain issues.

The National Council of Urban Indian Health (NCUIH) recently released an infographic showcasing the impact of Medicaid on health care for American Indian and Alaska Native (AI/AN) people. This document highlights data and statistics on AI/AN Medicaid coverage and enrollment, the impact of Medicaid funding on Indian healthcare providers, information on COVID-19 and Medicaid unwinding, and how Medicaid affects Urban Indian Organizations (UIOs) and urban AI/ANs.

About the Indian Health Service and Medicaid

Medicaid is a joint federal-state program that provides health insurance to eligible persons, including eligible AI/ANs. Indian healthcare providers bill Medicaid for services provided to Medicaid beneficiaries and Medicaid reimbursements are a critical source of funding to support the operation of the Indian Health system, comprised of the Indian Health Service (IHS), Tribal Health Programs, and UIOs. The federal government has a trust responsibility to provide federal health services to maintain and improve the health of AI/AN people. Due to historic underfunding of IHS, Medicaid is crucial to supporting healthcare services for AI/AN people and is critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health.

Medicaid Coverage in AI/AN Communities

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid, meaning almost 1/5 of the AI/AN population is covered by Medicaid. Of which, 46.2% of Medicaid enrollees are AI/ANs from the ages of 0-18, and 46.5% are from the ages of 19-64.

Medicaid and Urban AI/AN Communities

UIOs help serve the approximately 70% of AI/AN people who live in urban areas. In 2019, Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Comparatively, Medicaid covered 19.8% of all urban U.S. adults under the age of 65.

The Relocation and Termination Era and Federal Indian Boarding Schools have resulted in many AI/AN peoples living in metro areas, or cities. Below is a list of the metro areas that contain the highest population of AI/ANs who are enrolled in Medicaid. UIOs provide key services to almost all of the top metro areas where IHS-Medicaid beneficiaries live.

Medicaid: A Critical Source of Funding for Indian Health Care Providers

Medicaid reimbursements are a purely supplemental source of funding for IHS, as federal law prohibits appropriators from considering Medicaid revenue when determining IHS appropriations. Because the Medicaid program receives Mandatory appropriations and is not subject to the annual appropriations process, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries.

Covid-19 and Medicaid Unwinding

In March 2020, the Families First Coronavirus Response Act (FFCRA) Medicaid and Children’s Health Insurance Program (CHIP) “continuous coverage” requirement allowed people to retain Medicaid coverage and receive needed care during the COVID-19 Pandemic Public Health Emergency (PHE).

In December 2022, the Consolidated Appropriations Act, 2023 was signed into law, separating the continuous coverage provision from the COVID-19 PHE and setting an end date for the provision on March 31, 2023. This means that states may resume reviewing all Medicaid enrollees’ eligibility for coverage, a process referred to as “unwinding,” on April 1, 2023, and will begin ending coverage for those found ineligible. States must meet certain federal reporting and other requirements during the unwinding period. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage.

Native people may be at an increased risk of disenrollment in Medicaid and CHIP programs during the Medicaid unwinding period. In fact, Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. It is estimated that 12% of all AI/AN children and 6% of all AI/AN adults nationwide will lose CHIP or Medicaid coverage as state Medicaid programs return to normal operations. On April 24, NCUIH and 227 other organizations sent a multi-group letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra calling on the Administration to use their full powers provided in the Consolidated Appropriations Act of 2023 to safeguard Medicaid coverage and outlines specific steps the Administration can take to avoid wrongful terminations. Inadequate health insurance coverage is a significant barrier to healthcare access, and the loss of coverage may exacerbate the significant healthcare disparities faced by AI/AN communities.

The National Council of Urban Indian Health (NCUIH) recently released a Medicaid unwinding toolkit for urban Indian organizations (UIOs) as they prepare for changes in Medicaid coverage at the end of the COVID-19 pandemic Public Health Emergency (PHE). After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” This document outlines the impact of Medicaid unwinding on American Indians/Alaska Natives (AI/ANs) and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

Background

Prior to the pandemic’s PHE, Medicaid provided health insurance for more than one-third of AI/AN adults.  At the beginning of the pandemic, the Families First Coronavirus Response Act (FFCRA) Medicaid and Children’s Health Insurance Program (CHIP) “continuous coverage” requirement  allowed people to retain Medicaid coverage and receive needed care during the PHE.

After the PHE, states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and CHIP in a process known as “unwinding.” According to the Department of Health and Human Services (HHS), nearly 15 million people could lose their current coverage. This will be the single largest health coverage transition event since the first open enrollment period of the Affordable Care Act (ACA). This process is expected to disproportionately impact AI/ANs, particularly those living off-reservation.

While the unwinding process will vary by state, each state will have up to 12 months to start an eligibility renewal for every individual enrolled in their entire Medicaid and CHIP population. The unwinding process will create several challenges and will result in a loss or gaps in coverage for individuals.

Impact on AI/AN Communities

AI/ANs may be at an increased risk of disenrollment in Medicaid and CHIP programs once the PHE ends. Medicaid coverage losses are estimated to take twice the toll on AI/AN communities than they will take among non-Hispanic white families. Disenrollment of AI/ANs from Medicaid and CHIP will have significant consequences for the health and well-being of Native people – these programs are critical to fulfilling the United States’ trust responsibility to maintain and improve AI/AN health. Inadequate health insurance coverage is a significant barrier to healthcare access and often causes patients to delay or avoid medical care altogether. Alarmingly, when the PHE expires, 12% of all AI/AN children and 6% of all AI/AN adults nationwide are expected to lose CHIP or Medicaid coverage.

Medicaid-eligible AI/ANs face challenges in enrolling coverage due geographical remoteness, limited access to internet or phone service, language barriers, cultural factors, distrust of government programs, lack of knowledge of the benefits of coverage, or movement between non-reservation and reservation land.

Medicaid Unwinding and UIOs

UIOs play an important role in enrolling AI/ANs in Medicaid and CHIP as well as treating Medicaid beneficiaries, and will therefore, be critical in informing and helping eligible AI/AN maintain enrollment if eligible or explore other options. NCUIH’s resource highlights ways in which UIOs can work with states and other partners including Tribes and Tribal organizations, federal agencies like CMS and Indian Health Service (IHS), and their local communities:

Work with Your State

• Request a meeting your state regarding unwinding.
• Request that your state share renewal data via a spreadsheet or database so that you can speak with beneficiaries who utilize your services.
• Work with your state to develop targeted communication for AI/AN communities about the state’s unwinding activities.
  • States can leverage Unwinding Communications Toolkit materials published by the Centers for Medicare & Medicaid Services (CMS).
  • Ask your state to provide AI/AN-specific guidance on maintaining coverage through Affordable Care Act (ACA) Marketplace plans for those no longer eligible for Medicaid. AI/AN beneficiaries may have access to low-cost zero and limited cost-sharing plans on the Exchanges.
• Advocate that your state apply for Section 1902(e)(14)(a) waivers if necessary and applicable.

Work with Tribes

• Collaborate with Tribes to request a meeting with your state regarding unwinding.
• Develop partnerships with Tribes to provide necessary information to AI/AN beneficiaries.

Work with CMS, Indian Health Service (IHS), and Partner Organizations

• Request consultation and confer with CMS and IHS to discuss coverage loss concerns and oversight.
• Culturally appropriate materials are available through CMS, IHS, and the National Indian Health Board.

Work with Your Community

• Work with beneficiaries to ensure that their contact information is updated with the state Medicaid office, including addresses, emails, and phone numbers, to ensure that individuals receive information on renewals.
• Screen for potential Medicaid eligibility for all patients and refer current Medicaid recipients to your benefit specialists to update applications.
• Engage community partners, health plans, and the provider community to encourage individuals to update their contact information and to provide assistance with renewals.
• Educate patients, including utilizing outreach and educational materials in your clinic waiting rooms, patient rooms, and patient registration/in-take desks, regarding the unwinding and the risk of a loss in coverage.

On August 31, 2022, the US Food and Drug Administration (FDA) amended the previously issued emergency use authorizations (EUAs) for both the Moderna and the Pfizer-BioNTech (Pfizer) COVID-19 vaccines to authorize the use of bivalent formulations for boosters. The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) voted to recommend both the Moderna and Pfizer bivalent formulation boosters on September 1, 2022. This new formulation, which can be administered at least two months following the completion of a primary series or a previous booster dose, targets both the original virus and the current Omicron variants.  During a monthly call with Tribal and urban Indian organization (UIO) leaders, the Indian Health Service (IHS) stated that it started shipping the bivalent formulation the week of Labor Day and that these boosters will replace all booster formulations once rolled out. Currently, Omicron variants make up more than 99% of COVID-19 cases within the US.

As it stands, the monovalent (original) COVID vaccine is no longer the recommended booster for people ages 12 and up. In order for an individual to be considered ‘up to date’ on their COVID vaccination, they must have received the bivalent booster, regardless of previous booster status. Individuals who have previously caught COVID-19 can be vaccinated up to three months after the infection.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of the pandemic, AI/ANs were 3.5 times more likely to test positive, 3.2 times more likely to be hospitalized, and 2.2 times more likely to die to due COIVD-19.

Indian Country has had highly successful vaccine rollouts and UIOs have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of August 2022, AI/ANs have the highest vaccination administration rates in the US with 74.5% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.