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RESOURCE: COVID-19 Public Health Emergency Medicaid Unwinding Toolkit Released

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

Medicaid Unwinding Toolkit

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.

Medicaid Unwinding Toolkit

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

Medicaid Unwinding Toolkit

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 Unwinding Toolkit

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.

Bivalent COVID-19 Targeting Vaccine Formula Approved as Booster for 5-11 Year Olds

On October 12, 2022, the US Food and Drug Administration (FDA) amended the previously issued emergency use authorizations (EUAs) for both the Moderna COVID-19 and Pfizer-BioNTech COVID-19 bivalent vaccine formulas, authorizing their use as a single booster dose for those 5-11 years old. Following FDA’s announcement, Centers for Disease Control (CDC) released a decision memo, signed by Director Rochelle Walensky, expanding the recommendations for the use of bivalent vaccines matching the EUA expansions. As such, the Moderna formulation is now available for use in children six and older, at least two months post-completion of a primary series or previous booster dose. The Pfizer formulation is now authorized for use in children five and older, at least two months post-completion of a primary series or booster dose.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of it, 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 due to COVID-19. Indian country has had highly successful vaccine rollouts and urban Indian organizations (UIOs) have been instrumental in the success of vaccinating AI/AN populations in urban areas. As of October 2022, AI/ANs have some of the highest vaccination administration rates in the US with 75.7% of AI/ANs having received at least one dose, and 62.9% having completed the primary series. However, just under half of AI/ANs (47.3%) have received their first booster, and even less have received the second booster dose (37.4%), per CDC data.

The National Council of Urban Indian Health (NCUIH) will continue to monitor and provide updates on any changes in COVID-19 vaccine guidance, or other COVID-19 updates. For more information on the changes to COVID-19 vaccine guidance or the success UIOs have had with the vaccine rollout, see below:

New Omicron Targeting Vaccine Formula Approved as Booster Dose for Individuals 12 years and Older

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.

CDC Endorses Fourth COVID-19 Vaccine for Adults

On Tuesday, July 19, 2022, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, MPH, endorsed the CDC Advisory Committee on Immunization Practices’ recommendation for Novavax’s COVID-19 vaccine as another primary series option for adults 18 and older. Novavax’s vaccine, Adjuvanted, was granted an emergency use authorization on July 13, 2022, by the US Food and Drug Administration.

The Novavax vaccine, Adjuvanted, is another two-dose vaccine that will be available to administer to adults 18 and older in the coming weeks. The Novavax vaccine is administered three weeks apart and uses a more traditional technology for vaccine delivery. In total, there are now four different COVID-19 vaccines for adults 18 and older to choose from; Moderna, Pfizer, Johnson & Johnson, and Novavax.

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 due to du COIVD-19.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations have been instrumental in the success of vaccinating AI/AN populations in urban Areas. As of July 2022, AI/ANs have the highest vaccination administration rates in the US with 73% of AI/ANs having received at least one dose of one of the three previously available COVID-19 vaccines, per CDC data.

CDC Expands Eligibility of COVID-19 Boosters for Youth

On Thursday, May 19th, the Centers for Disease Control and Prevention (CDC) expanded eligibility of COVID-19 vaccine boosters for everyone 5-years and older. This expansion follows a meeting of the Advisory Committee on Immunization Practices’ (ACIP) and its recommendations. With this expansion of eligibility, the CDC recommendations for children are the following:

  • Children 5-11 years old should receive a booster shot 5 months post initial series of the Pfizer-BioNTech vaccine
  • Children 12 and older, who are immunocompromised, should receive a second booster at least 4 months after their first booster.

If you are eligible for a booster, be it the first or second dose of such, and you have not had one since December 2021, now is the time to do so. To see if you are eligible for a booster, click here.

COVID-19 and Native Communities

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of it, 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 due to COVID-19. Since the pandemic began, nearly 5 million kids, ages 5 to 11, have been diagnosed with COVID, 15,000 have been hospitalized, and over 180 have died.

Indian Country has had highly successful vaccine rollouts and Urban Indian Organizations (UIO) have been instrumental in the success of vaccinating AI/AN populations in urban areas. As of June 2022, AI/ANs have the highest vaccination administration rates in the U.S with 73% of AI/ANs having received at least one dose of the COVID-19 vaccine, according to CDC Vaccine Administration Data. As of June 2022, UIOs that use IHS vaccine distribution have administered over 174,105 doses of the COVID-19 vaccine and fully vaccinated 67,883 people.

NCUIH Endorses Bicameral Bill that Extends Grants to Urban Indian Organizations to Treat Long COVID

On April 7, 2022, Representative Ayanna Pressley (D-MA-07) and Senator Tammy Duckworth (D-IL) introduced the bicameral Targeting Resources for Equitable Access to Treatment for Long COVID (TREAT Long COVID) Act (H.R. 7482/S. 4015) to increase access to medical care and treatment for communities and individuals struggling with Long COVID. Specifically, this legislation would establish a grant program for eligible entities, including urban Indian organizations (UIOs), for the purpose of creating or enhancing capacity to treat patients with Long COVID through a multidisciplinary approach. The bill authorizes up to $2 million in grant funding to eligible entities and the period of a grant shall be up to three years, with an opportunity for renewal.

The TREAT Long COVID Act is co-sponsored by Rep. Donald Beyer (D-VA-8), Rep. Lisa Rochester (D-DE-1), Sen. Tim Kaine (D-VA), and Sen. Edward J. Markey (D-MA). The National Council of Urban Indian Health (NCUIH) endorses this bill that brings critical funding to UIOs to treat the lasting effects of COVID on the American Indian/Alaska Native (AI/AN) community.

“NCUIH is pleased to endorse Rep. Ayanna Pressley and Sen. Tammy Duckworth’s Targeting Resources for Equitable Access to Treatment for Long COVID Act. The COVID-19 pandemic has disproportionately impacted Native communities and we are left to deal with the devastating lasting impacts of this disease. We are grateful for the inclusion of urban Indian organizations to be eligible for these critical grants to address Long COVID conditions,” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

The bill was referred to the House Energy and Commerce and Senate Health, Education, Labor, and Pensions Committees. It currently awaits consideration. This bill has been added to the NCUIH legislative tracker and can be found here.

Background

Native communities face some of the harshest disparities in health outcomes of any population in the U.S. and are disproportionately impacted by the COVID-19 pandemic. American Indians and Alaska Natives have infection rates over 3.5 times higher than non-Hispanic whites, are over 3.2 times more likely to be hospitalized as a result of COVID-19 and have higher rates of mortality at younger ages than non-Hispanic whites.

The impact of COVID-19 on American Indian and Alaska Native health will continue beyond the pandemic. Lasting illness such as Long COVID need to be addressed.

NCUIH Resource: American Indian/Alaska Native Data on COVID-19

The TREAT Long COVID Act would expand treatment for Long COVID nationwide by:

  • Authorizing the Department of Health and Human Services to award grants up to $2,000,000 to health care providers, including community health centers;
  • Granting funding for the creation and expansion of multidisciplinary Long COVID clinics to address the physical and mental health needs of patients;
  • Prioritizing funding for health providers that plan to engage medically underserved populations and populations disproportionately impacted by COVID-19;
  • Ensuring that treatment is not denied based on insurance coverage, date or method of diagnosis, or previous hospitalization;
  • Encouraging ongoing medical training for physicians in Long COVID Clinics and other health care workers serving patients; and
  • Requiring grantees to submit an annual report on its activities that includes evaluations from patients.

Full Text of the House Bill

Full Text of the Senate Bill

Resource: American Indian/Alaska Native Data on COVID-19 Document Released on NCUIH Website

The National Council of Urban Indian Health (NCUIH) recently released an infographic about American Indian/Alaska Native (AI/AN) Data on COVID-19 on the NCUIH website. This document shows the disproportionate impacts of the COVID-19 pandemic on AI/ANs and Indian Country’s success with vaccinations for the virus. Native communities face some of the harshest disparities in health outcomes of any population in the U.S. and are disproportionately impacted by the COVID-19 pandemic. The impact of COVID-19 on American Indian and Alaska Native health will continue beyond the pandemic. Loss of American Indian and Alaska Native lives—especially the loss of elders—means loss of Native culture, including language, ceremonies, and more.

View the resource

Disproportionate Rates of COVID-19 Cases, Hospitalizations, and Mortality Among AI/ANs

American Indians and Alaska Natives have infection rates over 3.5 times higher than non-Hispanic whites, are over 3.2 times more likely to be hospitalized as a result of COVID-19 and have higher rates of mortality at younger ages than non-Hispanic whites.

AI/AN Children and Orphanhood Due to COVID-19

1 of every 168 AI/AN children experienced orphanhood or death of caregivers due to the pandemic, and AI/AN children were 4.5 times more likely than white children to lose a parent or grandparent caregiver.

Indian Country Lead on Vaccination Rates

As of February 2022, AI/ANs have the highest vaccination administration rates in the U.S with 70.6% of AI/ANs having received at least one dose of the COVID-19 vaccine, according to CDC Vaccine Administration Data. As of January 2022, UIOs that use IHS vaccine distribution have administered over 164,095 doses of the COVID-19 vaccine and fully vaccinated 65,957 people.

AI/AN Food Insecurity and COVID-19

NCUIH Endorses Bill to Understand and Address Long COVID, Including in Urban Indian Communities

On March 3, 2022, Senator Tim Kaine (D-VA) introduced the Comprehensive Access to Resources and Education (CARE) for Long COVID Act (S. 3726). This bill would improve research on long COVID as well as expand resources for those dealing with the long-term impacts of the virus. Specifically, the bill authorizes $50 million for each of fiscal years 2023 through 2027 to fund grants to eligible entities, including Tribes, Tribal organizations, and urban Indian organizations (UIOs), to support legal and social service assistance for individuals with long COVID or related post-viral illnesses. Additionally, UIOs are included in outreach and research activities of the long-term symptoms of COVID–19 by the Patient-Centered Outcomes Research Trust Fund.

“The National Council of Urban Indian Health (NCUIH) is pleased to endorse Senator Kaine’s Comprehensive Access to Resources and Education (CARE) for Long COVID Act. The pandemic has taken a disproportionate toll Indian Country and the public health crisis continues to affect Native communities experiencing symptoms of long COVID. This bill is a step in the right direction to better understand the long-term effects of the virus and provide support for those suffering.” – Francys Crevier (Algonquin), CEO, NCUIH.

The Comprehensive Access to Resources and Education (CARE) for Long COVID Act is co-sponsored by Senators Richard Blumenthal (D-CT), Tammy Duckworth (D-IL), Edward Markey (D-MA), and Tina Smith (D-MN). The bill was referred to the Senate Health, Education, Labor, and Pensions Committee. It currently awaits consideration.

This bill has been added to the NCUIH legislative tracker and can be found here.

Background

The COVID-19 pandemic has had devastating and disproportionate impacts on American Indians/Alaska Natives and continue to feel the lingering effects of the virus. This legislation aims to address this issue by:

  • Accelerating research by centralizing data regarding long COVID patient experiences;
  • Increasing understanding of treatment efficacy and disparities by expanding research to provide recommendations to improve the health care system’s responses to long COVID;
  • Educating long COVID patients and medical providers by working with the CDC to develop and provide the public with information on common symptoms, treatment, and other related illnesses;
  • Facilitating interagency coordination to educate employers and schools on the impact of long COVID and employment, disability, and education rights for people with long COVID; and
  • Developing partnerships between community-based organizations, social service providers, and legal assistance providers to help people with long COVID access needed services.

 

Senate Text of Bill

Senator Kaine’s Press Release

CDC and FDA Approve COVID-19 Boosters for Certain Individuals

On March 29, 2022, the Food and Drug Administration (FDA) authorized secondary booster doses of either Pfizer-BioNTech or Moderna COVID-19 vaccines for older adults and certain immunocompromised individuals. The Centers for Disease Control and Prevention (CDC) also updated its recommendations following the approval. The updated CDC recommendations acknowledge the increased risk of severe COVID-19 for the elderly, those over the age of 50 with underlying conditions, and are given based on available data on vaccine and booster effectiveness and FDA recommendations.

The FDA amended the emergency use authorizations with the following:

  • Individuals 50 years of age and older, who received their first booster of any authorized or approved COVID-19 vaccine at least 4 months prior, may receive a second booster dose of either the Pfizer-BioNTech COVID-19 Vaccine or Moderna COVID-19 vaccine
  • Individuals 12 years of age and older with certain immunocompromises, who received their first booster dose of any authorized or approved COVID-19 vaccine at least 4 months prior, may receive a second booster dose of the Pfizer-BioNTech COVID-19 vaccine.
  • Individuals 18 years of age and older, who received their first booster dose of any authorized or approved COVID-19 vaccine at least 4 months prior, may receive a secondary booster dose of the Moderna COVID-19 vaccine.

Background

American Indians and Alaska Natives (AI/ANs) have been disproportionately affected by the COVID-19 pandemic. At the height of it, 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 due to COVID-19. Due to NCUIH advocacy, UIOs were included in initial vaccine rollout plans and efforts.  NCUIH also partnered with Native American Lifelines – Baltimore and the University of Maryland to create a vaccine clinic for urban AI/ANs in the DC area.

KRC Articles

Social Determinants of Mortality of COVID-19 and Opioid Overdose in American Rural and Urban Counties

Authors: Yuhui Zhu, PhD, Zhe Fei, PhD, Larissa J. Mooney, MD, Kaitlyn Huang, BS, and Yih-Ing Hser, PhD

Publication Year: 2022

Last Updated: January 2022

Journal: Journal of Addiction Medicine

Keywords: Covid-19; Health Disparities; Infection Disease; Social Determinants of Health; Substance Abuse

 

Short Abstract: After adjusting for other covariates, the overall mortality rate of COVID-19 is higher in counties with larger population size and a higher proportion of racial/ethnic minorities, although counties with high rates of opioid overdose mortality have lower proportions of racial/ethnic minorities, a higher proportion of females, and are more economically disadvantaged. Significant predictors of rural counties with high mortality rates for both COVID-19 and opioid overdose include higher ratios of Black people, American Indians and Alaska Native people, and people with two or more races. Additional predictors for high-risk urban counties include population density and higher unemployment rates during the COVID-19 pandemic.

 

Source: Link to Original Article.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8815643/pdf/adm-16-e52.pdf

Type of Resource: Peer-reviewed scientific article

Disaggregating Data to Measure Racial Disparities in COVID-19 Outcomes and Guide Community Response — Hawaii, March 1, 2020–February 28, 2021

Authors: Joshua J. Quint, PhD1, Miriam E. Van Dyke, PhD, Hailey Maeda, MPH J. Keʻalohilani Worthington, MPH, May Rose Dela Cruz, Dr. Joseph Keaweʻaimoku Kaholokula, PhD, Chantelle Eseta Matagi, Catherine M. Pirkle, PhD, Emily K. Roberson, PhD, Tetine Sentell, PhD, Lisa Watkins-Victorino, PhD, Courtni A. Andrews, MPH, Katherine E. Center, PhD, Renee M. Calanan, PhD, Kristie E.N. Clarke, MD, Delight E. Satter, MPH, Ana Penman-Aguilar, PhD, Erin M. Parker, PhD, Sarah Kemble, MD

Publication Year: 2021

Last Updated: September 17, 2021

Journal: Centers for Disease Control & Prevention: MMWR

Keywords: Awareness, Cultural Sensitivity and Appropriateness, Data Collection, Health Disparities

Abstract: Research shows that Native Hawaiian and Pacific Islander populations have been disproportionately affected by COVID-19. Despite being distinctly different groups and populations, data from these populations is often grouped together in analyses. This unfortunately can limit the understanding of disparities among diverse groups such as Native Hawaiian, Pacific Islander, and Asian subpopulations. That is why, in order to assess disparities in COVID-19 outcomes among Native Hawaiian, Pacific Islander, and Asian populations an all inclusive study of all population groups was done using 21,005 COVID-19 cases and 449 COVID-19–associated deaths reported to the Hawaii State Department of Health (HDOH) during March 1, 2020–February 28, 2021.

Source: https://www.cdc.gov/mmwr/volumes/70/wr/mm7037a1.htm?s_cid=mm7037a1_w

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