Medicaid’s Essential Role in Improving the Mental Health of America’s Most Vulnerable Youth

Since well before the COVID-19 pandemic began, the number of young people diagnosed with a mental health need has been increasing, particularly among ethnic minorities, low-income households, and those involved with the child welfare and juvenile justice systems. In response, there has been an increased focus over the past year on strengthening behavioral health services for children and adolescents. A recent report from the Surgeon General describes “a national emergency in child and adolescent mental health” and offers several recommendations, including expanding access to response teams and funding community-based care systems to connect families with evidence-based interventions in their homes, communities, and schools.

Prevention and screening are also essential to meet the needs of young people at risk of mental health challenges. Fortunately, in 2013, the Centers for Medicare and Medicaid Services (CMS) issued guidance outlining the need to provide mental health and substance use treatment to members under age 21, including behavioral health screening and preventive services. Medicaid, which covers approximately 27 million young people, addresses this priority by offering the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires states to provide medically necessary services to people under 21 who may be experiencing a mental health need. EPSDT is more comprehensive than commercial insurance benefits, ensuring access to physical and mental health care that promote healthy development and to treatment that addresses symptoms before they worsen. This is a powerful tool; Medicaid-eligible youth are entitled to EPSDT benefits regardless of whether the service is covered in their state’s Medicaid program.

The recent launch of the national 988 suicide and crisis hotline has spotlighted efforts to ensure the availability of behavioral health mobile crisis teams. But preventive services and behavioral health screening can prevent youth from requiring an intervention in the first place. The Center for Medicaid and CHIP Services estimates that 11 percent of youth have a mental health diagnosis, and that at least two-thirds of those youth were not identified as receiving any mental health service. Attending to the wellness of caregivers is also part of ensuring healthy children and strong attachment with caregivers. In 2016, CMS issued guidance allowing for maternal depression screens as part of the EPSDT benefit. A 2018 survey found 31 states and Washington, D.C., allow maternal depression screening to be billed under the child’s Medicaid.

Read the full article from the Commonwealth Fund.

COVID-19 Boosters

The CDC recently recommended the following updated mRNA COVID-19 vaccine boosters to help restore protection that has waned since previous vaccination and target more transmissible and immune-evading variants:

  • The Moderna bivalent mRNA COVID-19 booster is authorized for people 18 and older.
  • The Pfizer bivalent mRNA COVID-19 booster is authorized for people 12 years and up.

These boosters are referred to as “bivalent” vaccines because they target both the original strain of COVID-19 and the Omicron BA.4 and BA.5 subvariants currently circulating in the United States. These updated boosters will help better protect us against these and future variants that might be closely related to Omicron.

Everyone who is eligible to receive the bivalent booster – including those who are moderately and severely immunocompromised – are recommended to receive ONE dose of the booster regardless of how many doses they have received previously. Those eligible may receive the updated booster if at least 2 months have passed since their last COVID-19 dose (either the final primary series dose or the last booster).

The original (monovalent) mRNA COVID-19 vaccine boosters are no longer authorized for people aged 12 years and older and can no longer be given to them, even if they had not previously received a monovalent booster dose. Children ages 5-11 should still receive the monovalent booster (at least 5 months after their second dose).

Routine Childhood Immunizations, Seasonal Influenza, & COVID-19 Vaccination can be co-administered

COVID-19 disrupted both in-person learning and routine well-child visits for many children. As a result, tens of thousands of children and adolescents have fallen behind on receiving recommended vaccines.

Timely vaccination is critical, as immunization schedules are designed to provide children with immunity early in life before they may be exposed to life-threatening diseases. Not only do delayed or missed vaccines leave children vulnerable to illness but when vaccination rates fall even just a little, vaccine-preventable diseases can spread easily.

We know from studies conducted throughout the pandemic that receiving a COVID-19 vaccine at the same time as routine immunizations is safe. If multiple vaccines are due, giving more than one vaccine at the same visit is important because it increases the probability that an individual will be up to date with vaccines.

In addition, with both influenza and COVID-19 viruses circulating, getting both the Flu and COVID-19 vaccines is important for prevention of severe disease, hospitalization, and death. CDC recommends health care providers offer influenza and COVID-19 vaccines at the same visit, with each dose administered in separate limbs.

Blood Donations Urgently Needed

The back-to-school season is a critical time for our blood supply

As summer ends and the school year begins, the Washington State Department of Health (DOH) and Northwest Blood Coalition urge eligible blood donors to schedule donations.

According to the Northwest Blood Coalition, high school and college students make up almost 25 percent of blood donations. “High schoolers and college-age youth are critically important members of our donor base,” shared Vitalant Regional Director Jennifer Hawkins.

The Northwest Blood Coalition is formed by four blood donation centers currently serving Washington state: Vitalant, Cascade Regional Blood Centers, BloodworksNW, and the American Red Cross Northwest Region. As Red Cross Regional Services Executive Angel Montes describes, “The Northwest Blood Coalition’s primary focus is to ensure a safe, reliable blood supply for our community.” DOH collaborates with the coalition to support this vital work.

“Blood centers enthusiastically welcome students back to school,” said Curt Bailey, President and CEO at BloodworksNW. “We want to engage those interested in the rewarding, lifesaving act of donating blood—whether they’ve done it before or it’s their first time.”

Every two seconds, someone in the U.S. needs blood. Donated blood is crucial for those undergoing surgeries, cancer treatments, blood disorder treatments, complications from childbirth, and other serious conditions and injuries. However, blood supply shortages continue to be a nationwide concern, and Washington state is no exception.

“We know that people want to help. Donations tend to slow when school is on break and summer activities are happening,” added Christine Swinehart, President and CEO at Cascade Regional Blood Centers. “As we look toward fall, we want to remind folks that now is a great time to donate!”

To learn more and schedule an appointment, please visit the blood center websites linked above.

Department of Homeland Security Finalizes “Public Charge” Immigration Rule

The Department of Homeland Security (DHS) has finalized a rule defining the criteria it uses when determining whether a person can be denied a visa and/or legal residency because they are likely to become a “public charge.” The final rule comes on the heels of the proposed rule, published February 24, 2022, and is the latest chapter in a long series of regulatory and legal actions surrounding the public charge policy. It includes several provisions that directly affect older immigrants and immigrants with disabilities, their families and caregivers.

For more information and background on the history of the public charge policy, see ACL’s March 2022 blog post on the Notice of Proposed Rulemaking and the July 2021 blog post on the history of public charge rulemaking as well as resources from the Department of Homeland Security.

What’s most important for older immigrants and immigrants with disabilities to know?

Someone may be considered a “public charge” if they are likely to become primarily dependent on the government for subsistence. This is evaluated by looking at prior and current use of certain public benefits as well as other factors such as age, health, and financial resources.

Participation in most public benefits, including ACL’s programs, will not adversely impact a citizenship or residency determination under the new rule. The ONLY public benefits considered in a public charge determination are:

  • Long-term institutionalization funded by the government (for example, Medicaid-financed care in a nursing facility). Receiving Medicaid Home and Community-Based Services (HCBS) or other Medicaid health care benefits will not affect a public charge determination.
  • Direct cash assistance programs, including Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF).

This is a codification of DHS’ 1999 Field Guidance (the policy that is currently in place). It solidifies DHS’ long-standing position on which public benefits will be considered in a public charge determination and which will not.

What are the major provisions of the final rule?

DHS received 233 comments on the proposed rule, including many from the aging and disability community. The final rule provides responses to many of those comments, explaining why policy changed or remained the same. The final rule closely mirrors the proposed rule with a few exceptions. The major provisions include:

  • Receiving Medicaid Home and Community Based Services (HCBS) will not factor into any public charge determination. Medicaid HCBS, as well as acute care benefits, will not be considered.
  • Long-term institutionalization at government expense will be factored into a public charge determination and while “long-term” is not explicitly defined, the rule includes guardrails. While the rule did not define what constituted “long-term” institutionalization with a hard threshold or day limit, it did specify that short-term residential care for rehabilitation or mental health treatment would not be considered. Long-term institutionalization also does not include imprisonment for conviction of a crime. DHS will collaborate with the Department of Health and Human Services to develop sub-regulatory guidance to help guide DHS agents’ evaluation of past or current institutional stays.
  • Evidence may be presented to show unjustified institutionalization in violation of federal law. DHS recognizes that some people are forced to live in institutions due to the unavailability of HCBS and in violation of their rights under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act (as interpreted by the Supreme Court in Olmstead v. L.C.). As a result, an applicant for admission to the United States or an immigration status change may present evidence to show their institutionalization was in violation of federal law, thus mitigating negative weight that may be put on that period of institutionalization during a public charge determination.
  • No single factor alone is determinative of whether someone may be deemed a “public charge.” DHS will perform a “totality of the circumstances test” considering both past and current use of publicly funded institutional care and cash assistance. The test also includes an evaluation of five statutory factors: health, age, family status, assets/resources/financial status, education/skills to determine likelihood of primary dependence on the government for support. No single factor is determinative, however. Thus, past or current institutionalization, receipt of cash benefits, poor health or advanced age alone is not sufficient to render someone a public charge.
  • Disability alone is not sufficient for a determination that individual is likely to become a public charge. Disability, as defined in Sec. 504 of the Rehabilitation Act of 1973, cannot be the sole basis for a determination that an that individual is in poor health, is likely to require long-term institutionalization at government expense, or is likely to become a public charge due to any other factor.
  • DHS will consider the medical evaluation performed by a physician when evaluating a non-citizens health: In the proposed rule, DHS did not specify evidence it would consider as a part of the statutory minimum factor evaluation. In the final rule, DHS clarifies it will accept information submitted via forms it is already gathering as a part of the admission, citizenship, or naturalization process. The standard medical report and vaccination record  will be considered as evidence for the health factor. This report captures information on a non-citizens chronic health conditions and/or disabilities and will be used by DHS agents in the “totality of the circumstances” analysis. DHS will work with HHS on guidance to agents to ensure disability competency when evaluating medical conditions or disabilities that appear on the medical report.

What does this mean for immigrant communities moving forward?

Non-citizens should apply for and use the public benefits to which they are entitled, with the understanding that:

  • Long-term institutionalization paid for by Medicaid (or another public source) or cash benefits like SSI or TANF may, but will not necessarily, adversely affect immigration decisions under the public charge rule.
  • Using other services – such as Medicaid HCBS, services provided through ACL’s programs, or the Supplemental Nutrition Assistance Program (SNAP) – will not affect immigration decisions under the public charge rule.

The final rule will be effective on December 23, 2022, and will be published in the Federal Register on September 9, 2022.

Read more:

Release from the U.S. Department of Health and Human Services: New Rule Makes Clear that Noncitizens Who Receive Health or Other Benefits to which they are Entitled Will Not Suffer Harmful Immigration

Omicron COVID-19 vaccine boosters now authorized for certain individuals

The Washington State Department of Health (DOH) and other healthcare providers will soon begin offering Omicron variant-targeted bivalent booster doses of the Pfizer-BioNTech and Moderna COVID-19 vaccines following authorization by the U.S. Food and Drug Administration (FDA), and recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunizations Practices, and the Western States Scientific Safety Review Workgroup.  

The bivalent vaccines combine the companies’ original COVID-19 vaccine compositions with BA.4 and BA.5 spike protein components, providing additional protection by targeting variants that are more transmissible and immune-evading. The primary COVID-19 vaccine series will stay the same, given their proven efficacy in preventing serious illness, hospitalization, and death from COVID-19. DOH’s updated booster dose recommendations are as follows: 

  • People ages 12 – 17 who have completed a primary vaccine series can receive the Pfizer-BioNTech bivalent booster at least two months after their most recent dose. 
  • People 18 and older who have completed a primary vaccine series can receive either company’s bivalent booster at least two months after their most recent dose. 
  • Those ages 5 – 11 who have completed Pfizer-BioNTech’s primary vaccine series should continue to receive the company’s original monovalent booster at least 5 months after their most recent dose. 
  • Children ages 6 months – 4 years are currently not authorized for any COVID-19 booster doses. 
  • People ages 12 and over who currently have appointments to receive COVID-19 booster doses will need to contact their providers to ensure the bivalent booster is available; if not, those appointments will need to be rescheduled, as the former monovalent booster doses are no longer authorized for this age group. 

“We’re excited this updated bivalent booster will help increase protection against the Omicron variants as we head into the fall season,” said Tao Sheng Kwan-Gett, MD, MPH, Chief Science Officer. “As SARS-CoV-2 changes, so must the tools we use against it – this update helps ensure that vaccines and boosters will continue to be the most effective ways to reduce the risk of hospitalization and death, and keep those most at-risk healthy and safe.” 

An initial allocation of 191,100 bivalent booster doses is currently en route to providers throughout the state and will be available beginning the week of September 5 after the Labor Day holiday. Subsequent weekly allocations will follow, building the state’s inventory levels over time. DOH urges the public to remain patient, as we expect initial demand to exceed available inventory before resolving in the coming weeks, and to visit Vaccine Locator or call the COVID-19 Information Hotline at 1-800-525-0127 to find available resources near them. 

Be safe this Labor Day weekend and National Preparedness Month

As we head into Labor Day weekend, the Washington State Department of Health (DOH) encourages everyone to keep health and safety in mind.

For many, Labor Day weekend is not only a celebration of our workforce and labor movement. It’s also an opportunity to gather and enjoy the summer season as it draws to a close.

“We want people in Washington to have fun this holiday weekend, and to do so as safely as possible,” said Nathan Weed, Chief of Resilience. “Whether having a barbecue, celebrating on the water, or joining other activities, a little planning and awareness can go a long way in preventing an illness or accident.”

Here are some easy—yet impactful—ways to prepare for a safe, healthy holiday:

September is also National Preparedness Month. Public health agencies use this annual observance to promote emergency preparedness and encourage community members to take action before, during, and after an emergency. From an infectious disease outbreak to a natural disaster, DOH is ready to respond to help address and maintain the safety of Washingtonians.

Watch for additional preparedness tips and guidance through the month of September on the DOH website and social media.

FDA Authorizes Emergency Use of JYNNEOS Vaccine for Monkeypox

The U.S. Food and Drug Administration (FDA) issued an emergency use authorization for the JYNNEOS vaccine to allow healthcare providers to use the vaccine for individuals 18 years and older who are determined to be at high risk for monkeypox infection.

Visit the Centers for Disease Control and Prevention (CDC) for more information, in English and Spanish, on monkeypox.

Read the full announcement from the FDA here.

Unraveling the Interplay of Omicron, Reinfections, and Long Covid

The latest covid-19 surge, caused by a shifting mix of quickly evolving omicron subvariants, appears to be waning, with cases and hospitalizations beginning to fall.

Like past covid waves, this one will leave a lingering imprint in the form of long covid, an ill-defined catchall term for a set of symptoms that can include debilitating fatigue, difficulty breathing, chest pain, and brain fog.

Although omicron infections are proving milder overall than those caused by last summer’s delta variant, omicron has also proved capable of triggering long-term symptoms and organ damage. But whether omicron causes long covid symptoms as often — and as severe — as previous variants is a matter of heated study.

Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, is among the researchers who say the far greater number of omicron infections compared with earlier variants signals the need to prepare for a significant boost in people with long covid. The U.S. has recorded nearly 38 million covid infections so far this year, as omicron has blanketed the nation. That’s about 40% of all infections reported since the start of the pandemic, according to the Johns Hopkins University Coronavirus Research Center.

Long covid “is a parallel pandemic that most people aren’t even thinking about,” said Akiko Iwasaki, a professor of immunobiology at Yale University. “I suspect there will be millions of people who acquire long covid after omicron infection.”

Read the full article from KHN.

Department of Health releases updated COVID-19 guidance for K-12 schools & child care

The Washington State Department of Health (DOH) has released its updated COVID-19 guidance for K-12 schools and child care. The guidance takes lessons learned from the first two and a half years of the pandemic, and outlines both required and recommended measures for the 2022-23 school year to help reduce COVID-19 transmission in school and child care settings. Schools, child care providers, and families can expect limited changes focused on clarifying and simplifying the guidance.

“We are entering a new stage of coexisting with COVID-19 in our communities, knowing that COVID-19 is here to stay for the foreseeable future,” said Umair A. Shah, MD, MPH, Secretary of Health. “DOH also recognizes the importance of being able to maintain in-person learning for children, and the fundamental links between education and long-term health outcomes.”

Clarified requirements and recommendations in this school year’s guidance include:

  • Students, children, and staff who test positive for COVID-19 are required to stay at home and isolate for 5 days. Repeating initial COVID-19 testing will not affect this requirement.
  • Students, children, and staff returning from 5 days of isolation should wear a well-fitted mask from days 6 to 10. Those returning are encouraged to test before doing so.
  • Schools and child care providers are no longer required to directly notify high risk individuals of exposure but must continue to have a process in place to inform students, staff, and families of cases and outbreaks.
  • Schools and child care providers continue to be required to report outbreaks (3 or more cases within a specified core group) to local health jurisdictions (LHJ) and to have a system in place to respond.

DOH continues to encourage schools and child care providers to consider their local context when selecting any additional measures to help reduce COVID-19 transmission in schools and child care settings and to coordinate with their LHJ, particularly during times of outbreak. Schools, child care providers, and the LHJ may choose to continue to implement more protective measures, depending upon their context, to help ensure students, children, and staff can continue in-person activities safely.

While the guidance is specific to COVID-19 prevention, it can also help to reduce transmission of other common respiratory viruses such as influenza. DOH has also developed a brief for schools and a brief for child care providers to provide a high-level overview on changes to the guidance.

COVID-19 vaccinations remain the best protection for everyone against hospitalization and severe disease from COVID-19. The COVID-19 vaccine is now available for children 6 months and older. Booster doses are also available for children 5 years and older. DOH encourages all families to vaccinate their children if they are eligible, in consultation with health care providers.

988 Suicide and Crisis Lifeline Launches

988 is the new, nationwide, three-digit dialing code for the Suicide and Crisis Lifeline. The 988 dialing code connects people via call, text, or chat, to the existing National Suicide Prevention Lifeline (NSPL) where compassionate, accessible care and support are available for anyone experiencing mental health-related distress. 988 is the newest addition to the state’s network of crisis center providers and will not replace any crisis call centers in Washington. The current NSPL number, 1-800-273-TALK (8255), will remain active along with the new 988 dialing code.

“Thanks to the many partner organizations and agencies who have made this resource possible,” said Governor Jay Inslee. “In the same way 911 transformed our ability to respond to emergency safety or health situations, 988 will transform our ability to connect people to help in behavioral and mental health crisis situations.”

“Providing an easy-to-remember, three-digit number is an important step to accessing potentially life-saving support,” said Umair A. Shah, MD, MPH, Secretary of Health. “We are dedicated to enhancing and expanding behavioral health crisis response and suicide prevention services for all Washingtonians.”

In addition to activating a new dialing code for anyone experiencing suicidal or mental health-related crisis to call, the 988 Suicide and Crisis Lifeline also allows text messaging as part of increasing access to services for youth and individuals with different abilities. People can also dial or text 988 if they are worried about a loved one who may need crisis support. 988 will be available 24/7 and is free and confidential.

Call services will be available in Spanish, along with interpretation services in over 250 languages. Spanish speakers may reach the Spanish Language Line by pressing 2 after dialing 9-8-8 or 1-800-273-TALK (8255). Text and chat services are available in English only.

Veterans and service members may reach the Veterans Crisis Line by pressing 1 after dialing 9-8-8 or 1-800-273-TALK (8255). Soon, Washington will also be able to launch a Native and Strong Lifeline, dedicated to serving Washington’s American Indian and Alaska Native individuals.

People who are deaf, hard of hearing, and TTY users should use your preferred relay service or dial 711 then 1-800-273-8255.