COVID-19 Priorities Checklist for State Leaders

COVID-19: State Responses and Best Practices

States and state officials are on the front lines of the response to COVID-19. The challenge we face as a nation is unprecedented in recent memory, with twin crises in public health and the economy that may stretch for months. The day-to-day management of this emergency has fallen to governors and state leaders, just as a slowing economy means that they will need to do more with less.

USofCare is monitoring the actions of state officials, policy experts, health care providers, and concerned citizens across the country. We have assembled the comprehensive approaches that states are launching to tackle the public health and economic ramifications of COVID-19, and know that states can learn a great deal from the collective wisdom of other states.

States’ immediate responses fall into five priority areas:

1. Take action to slow the spread of the virus.
2. Build and sustain the health care workforce and supply reserve necessary to take on pandemic.
3. Ensure access to health care for those with COVID-19 and those losing their coverage as a result of the economic downturn.
4. Protect at-risk populations most vulnerable to COVID-19.
5. Lay groundwork for the long-term approach to the epidemic and economic recovery.

We recognize this list is just the beginning of the monumental work that states will face in the coming months. As states focus on the most immediate needs, we understand the importance of the long-term, ongoing work that will ultimately be necessary to help people, the health care system and the economy recover from COVID-19. With many state legislatures unable to meet in person, the majority of actions can be taken administratively and through statewide leadership and coordination. Our goal is to continue to elevate best practices and push forward new approaches to the unprecedented medical and public health challenges that more American cities and states will have to confront.

Priority #1: Take action to slow the spread of the virus.

Throughout the COVID-19 pandemic, governors and local leaders have been ahead of the federal government in encouraging and enforcing both social distancing and shelter in place recommendations. The mitigation approaches that follow will not be effective without successfully “flattening the curve,” spreading out the burden on the health care system over the coming months. Public health officials have the expertise to make the best judgments about which interventions will best meet a state’s needs at a particular time.

• Move forward with mitigation measures. 47 closed K-12 schools (3 relying on local closures), all required or encouraged limited bar and restaurant service, and to date 22 have issued statewide “shelter in place” orders or recommendations. In 15 states where governors have yet to call for “shelter in place,” local governments have already directed residents to stay home.
• Request emergency support. Every state and territory has declared a public health or state emergency.
  • 42 states, Guam, Puerto Rico, and Washington, DC have activated their national guards. Soldiers are assisting with tasks ranging from constructing disaster response tents, administering COVID-19 tests, and distributing food.
  • At least 17 states have requested a FEMA Major Disaster Declaration, and 12 have already been approved, including CA, FL, IA, IL, LA, MD, MO, NC, NJ, NY, TX, and WA. This declaration makes funding available from the existing $42 billion Disaster Relief Fund on a cost-sharing basis (75% federal). Funding can be made available for a wide range of necessary services, including disaster SNAP, unemployment assistance, and legal aid; however, the President has only approved funding for crisis counseling and public safety measures so far.
• Use the best available information and guidance. A wide variety of tools to help states and localities make determinations about the best public health needs for their area are being created every day, including:
  • The COVID-19 Preparedness dashboard, which provides a wide range of resources, including guidelines on how to slow and reduce transmission.
  • COVID Act Now, which models the state-by-state impact of social distancing and shelter in place measures compared with taking no action.
• Create authority to respond rapidly to changing conditions. New York passed legislation granting the Governor the authority to issue any directives necessary to respond to the emergency, consistent with state and federal Constitutions, which enables the state to take appropriate actions quickly.

Priority #2: Build and sustain the supplies, health system capacity, and workforce needed to overcome the immediate medical challenge.

States must continue to build their own health care system’s capacity and obtain the supplies that health care workers need to do their jobs and keep them safe. Frontline medical workers, including doctors, nurses, parademics, EMTs, respiratory therapists, and the countless other workers who come into direct contact with patients, are the core of any state’s response; protecting their ability to do their job is critical for success.

• Eliminate barriers that may keep frontline health care workers from doing their jobs. The most pressing needs will vary by facility and by worker, but states should work closely with health care systems to support frontline workers in every possible way.
  • Prioritize mental health needs of frontline workers. While the nation as a whole will face significant mental health needs over the coming months, state leaders should work closely with health systems to ensure that the mental health care needs of frontline medical workers are immediately met, and work to help systems identify additional mental health workforce capacity to provide support if necessary.
  • Ensure emergency workers have child care available. For example, Washington, DC and Vermont, are using schools to provide childcare for health care workers and/or other “essential persons” during the crisis.
  • Utilize vacant dorms or hotel capacity for medical workers who have been exposed and need to avoid exposing their families. As the crisis grows, Airbnb and the American Hotel and Lodging Association are launching initiatives to connect beds with state needs. States can serve an important role by identifying and coordinating this capacity to minimize the burden on already strained health care systems.
• Utilize all available flexibility to augment the current workforce.
  • Temporarily loosen licensing and scope of practice requirement. Many states are already taking action, both on licensure and scope of practice.
    • Wyoming, Maryland, and Washington, among others, are offering interstate reciprocity of practice to a range of medical professionals–who are licensed and in current good standing in the state but not registered in the state. This can be extended to pharmacists as well, as seen in Massachusetts.
    • Tennessee and Pennsylvania have taken steps to loosen requirements for nurse practitioners.
    • Kansas is providing “temporary emergency licenses” for any applicant the Kansas State Board of Healing Arts deems qualified. 5/10
    • Texas has waived regulations and fees to get more nurses into the workforce, and fast-tracked temporary licensing for out-of-state medical professionals.
  • Coordinate recruitment of additional personnel and volunteers.
    • New York City has called for state-certified, non-registered health care workers willing to support health care facilities, and is matching them to where they are most needed.
    • States can also take steps to ease the re-licensing process for retired medical professionals. Oregon is allowing providers to submit emergency reactivation applications, while Maryland has moved to allow inactive clinicians to practice without first reinstating their license.
  • Allow medical students–with necessary approvals–to play certain clinical roles. Missouri already has a state law allowing these “assistant physicians” to perform certain, limited clinical duties, and Arkansas is allowing medical residents to apply for emergency temporary licenses.
  • Allow foreign trained providers who have not completed a U.S. residency program to practice in certain roles, or provide them with an expedited pathway to licensure if they meet certain criteria, like successful completion of an equivalent examination of the USMLE or COMLEX-USA levels 1-3.
• Eliminate non-essential and elective procedures to free up supplies and health system capacity. States have executive power to halt non-essential procedures that can be postponed or cancelled. At least 27 states have taken action in this area, which frees up important supplies and equipment for COVID-19 related care.
• Dedicate a state COVID-19 resource coordinator and inventory supplies. Understanding the supply of vital resources and equipment allows state leaders to direct resources to where they are most needed. Colorado, New Jersey, and Minnesota have issued executive orders requesting non-health care businesses and organizations in the state to inventory their supplies of certain equipment, including PPE and ventilators, and report and prepare to send it to the state. Colorado’s Emergency Operations Center is empowered to allocate any supplies that the state receives. Texas has also identified a supply chain director.
• Encouraging limitation and donation of Personal Protective Equipment. Many non-health care related businesses utilize PPE. Oregon issued an order encouraging all entities that use PPE, including in commercial, construction, farming, and manufacturing sectors to cancel or postpone non-essential uses. States may additionally choose to recommend limitation of PPE usage, or to encourage donation of surplus supplies to statedesignated resource coordinators. Such businesses could include: nail salons, spas, tattoo and piercing shops, K-12 schools, universities, science programs, and construction companies.

Priority #3: Ensure access to health care for those with COVID-19 and those losing their coverage as a result of the economic downturn.

The coming weeks and months will bring significant health care challenges, both for those who contract COVID-19 and require health care, and for those whose access to care is threatened or disrupted as a result of hospital overcapacity or job loss. Reliable access to affordable care is all the more critical during a public health emergency, and there are several common sense steps that states should consider to protect health care for those who need it:

• Utilize Medicaid and Medicaid flexibilities to the fullest extent possible. These can include:
  • Utilizing Medicaid to pay for COVID-19 testing. The Families First Coronavirus Response Act, passed on March 18, 2020, provides states with the option to provide Medicaid coverage for COVID-19 testing for uninsured residents with 100% federal financing. States should utilize this opportunity to protect their residents and eliminate a financial barrier to people getting tested.
  • Using 1135 waivers. States have the pathway to waive some provider screening requirements, suspend prior authorization requirements, and waive public notice and tribal consultation timelines, among other tools. CMS approved 34 states’ waivers for various permutations of these options, and created a checklist of commonly requested waiver flexibilities to aid states in crisis.
  • Easing enrollment and re-enrollment processes. States can ease enrollment and re-enrollment processes by creating streamlined enrollment pathways, temporarily delaying renewals, and temporarily suspending periodic eligibility checks in order to reduce the burden on both Medicaid agencies and beneficiaries. For example, states can utilize hospital presumptive eligibility–or presumptive eligibility through other qualified entities–to more easily enroll people in Medicaid who are likely to be eligible. States can also inform individuals applying for other benefits, such as unemployment benefits, about their coverage options through Medicaid.
  • Extending coverage of prescription drugs. Through Medicaid, states should consider covering 90-day supplies of maintenance medications, allowing beneficiaries to receive refills in advance, and offering coverage for home delivery of prescription drugs.
  • Temporarily expanding Medicaid. States that have not yet expanded Medicaid should consider doing so temporarily for the duration of the national emergency. This will provide states with financial relief and immediate access to health care for populations who are currently uninsured or whose incomes have recently dropped, making them newly-eligible for Medicaid if their state expands.
• Immediately open Special Enrollment Periods (SEPs) in state exchanges. States should consider making plans available for the next 30-90 days for uninsured residents and those impacted by COVID-19. Ten states, including Rhode Island and Nevada, have opened Exceptional Circumstance SEPs for qualifying individuals. States 7/10 like New Hampshire and New Jersey, two of the 32 that rely on the federally facilitated marketplace, have requested that CMS open a 60-90 day SEP.
• Ensure that COVID-19 treatment is affordable. Battling COVID-19 should not financially devastate families. States can act to limit out of pocket exposure for treatments and dedicate funding to make care available to people who are uninsured. So far, two states (NM and MA) and DC require that almost all COVID-19 treatment be administered without cost sharing.
• Eliminate all surprise billing related to COVID-19. With intensive care and experimental treatments potentially needed, COVID-19 care could quickly get very expensive for patients. States can pass legislation, similar to what has been done related to surprise billing prior to the pandemic, to prevent surprise bills arising from the diagnosis and treatment of COVID-19. Thirteen states have already enacted and/or implemented comprehensive surprise billing protections, but there is opportunity for more states to follow in their footsteps, specifically related to COVID-19. This action will mean people won’t risk financial devastation after they receive needed care.

Priority #4: Protect individuals most at-risk for COVID-19.

Controlling COVID-19 means asking many to isolate at home, potentially for long periods of time. At a time when social distancing poses complications to traditional approaches to home care, many of our most at-risk neighbors have significant health needs that still need to be met.

• Provide more care remotely through telehealth. While federal legislation has expanded access to telehealth services for COVID-19-related care, many people with significant health care needs must rely more heavily on virtual care as in-person health care services are curtailed.
  • States should require insurance companies to cover telehealth for non-COVID-19 related medical care, including mental health and substance use disorder treatments, for the duration of the emergency, and provide reimbursement parity for telemedicine-based services.
  • Medicaid programs should cover a full range of telehealth services and temporarily waive restrictions that would make it difficult for someone to utilize telehealth from their home. Ohio and New Jersey, among others, directed their Medicaid programs to broaden access to telehealth services for the duration of the emergency. Many also waived the initial face-toface visit that is typically required, including the state of Arkansas.
• Focus on at-risk populations. States need to develop and implement strategies to address the needs of the most vulnerable in their communities. For example, people experiencing homelessness face unique barriers adhering to social distancing guidelines.
  • Local officials in California, Washington, and Illinois are procuring hotel rooms to provide secure housing for those who may not otherwise be able to safely selfisolate.
  • Washington’s King County is reducing the jail population to make facilities safer.
  • In New York City, a group of private sector individuals have come together to form the New York City COVID-19 Rapid Response Coalition. This coalition is working to connect and activate a network of resources to serve vulnerable populations in their homes, reducing their utilization of critical and currently unavailable hospital capacity.

Priority #5: Lay groundwork for the long-term approach to the epidemic and economic recovery.

Effectively navigating COVID-19 requires state leaders to mitigate the immediate medical surge while identifying and planning for the challenges just over the horizon. The social distance-based approach buys time for states, public health officials and health systems to stand up the testing and contact tracing capacity that will be necessary to ultimately respond to the pandemic. However, state leaders will eventually need to shift from a triage operation to leading a recovery, and take forward-looking steps to mitigate future waves of COVID-19 later this year and into next year.

• Build a robust testing strategy and public health response. Managing and containing COVID-19 will require more capacity to test suspected cases and trace the contacts of those infected. State officials need to begin this medium-range planning now, and invest in building public health infrastructure and workforce that will meet this need. For example, the Greater Seattle Coronavirus Assessment Network (SCAN) is a new surveillance effort launching in Seattle and King County that will work to identify the true number of people with the virus to better understand the public health impact.
• Anticipate insurance market shocks. Early estimates suggest that the health care costs of treating COVID-19 will be significant. Health insurers did not anticipate these expenses when they established their rates for 2020, so without action, employers and individuals will likely see jumps in their health insurance premiums for 2021. While the impact will likely vary by state, leaders in some states with significant COVID-19 caseloads and expenses may need to act to mitigate large increases to make sure that people can afford the health care coverage they need next year.

Through all the daily noise and confusion, remaining focused on the best practices in these 5 immediate priority areas will enable state leaders to address the crisis, reassure the public, and lay the groundwork for a strong recovery from COVID-19. Over the coming weeks and months, USofCare will continue to seek out and solicit a wide range of creative solutions to help state leaders confront this crisis.