Health Equity blog

On September 9, the Department of Health and Human Services (HHS), Department of Labor (DOL), and the Treasury Department released new final rules implementing the Mental Health Parity and Addiction Equity Act (MHPAEA). As the country continues to struggle with an escalating mental health and substance use disorder (SUD) crisis, MHPAEA has failed since its enactment nearly 16 years ago to reduce barriers that individuals encounter in trying to access critically needed mental health resources through their health plans. In fact, disparities have not only persisted, but they have also actually grown. One of the hallmarks of the new rules is prohibiting insurers from using nonquantitative treatment limitations (NQTLs), such as prior authorization requirements and other utilization management, which are more restrictive than the predominant NQTLs applied to medical/surgical benefits in the same classification. Various aspects of the new rules take effect beginning as early as January 1, 2025.

The Biden-Harris Administration’s American Rescue Plan Act of 2021 provided that, through Medicaid block grants, the government offers states a new option for supporting community-based mobile crisis intervention services for beneficiaries. Mobile crisis intervention services are essential to providing rapid responses to individuals where they are located when they are experiencing a mental health or SUD crisis. These mobile services are made available 24/7/365 and are staffed with appropriately qualified behavioral health providers trained to manage such interventions. As with the 19 other states and the District of Columbia before it, the Centers for Medicare and Medicaid Services’ (CMS’s) approval of the New Hampshire State Plan Amendment means that the state will also receive Medicaid funding to directly connect beneficiaries to specialized mental health services and provide follow-up check-ins for individuals experiencing a mental health or SUD crisis.

In accordance with the Biden-Harris Administration’s ongoing effort to support programs in furtherance of the ACA’s implementation, it recently announced plans to award a new $100 million tranche of funds to organizations that serve as Navigators. Navigators offer free assistance to individuals residing in underserved communities, as well as others, to find and enroll in affordable health coverage made available through the DHHS sponsored Marketplace accessible through healthcare.gov. Navigators can also assist individuals with obtaining Children’s Health Insurance Program (CHIP) coverage if applicable. CMS is awarding these grants in advance of the Marketplace open enrollment period that begins November 1.

Florida and Texas have both implemented laws requiring certain hospitals to inquire as to patients’ immigration status when seeking care. Florida’s statute, adopted in 2023, mandates that hospitals receiving Medicaid payments query patients about their immigration status. In August, Governor Abbott of Texas took similar measures by signing an Executive Order that requires hospitals operating in Texas to collect and report the frequency and cost of certain services, including inpatient discharges and ED visits, involving patients present in the U.S. unlawfully. Hospitals participating in Medicare in both states are still required by Emergency Medical Treatment & Labor Act (EMTALA) to medically screen all persons seeking emergency care and provide necessary stabilizing treatment to those who have an emergency condition, regardless of ability to pay or insurance status. Under both state laws, hospitals must also inform patients during the course of collecting immigration status information that their responses will not affect their ability to receive care. Nonetheless, the law may have a chilling effect and deter patients from ever seeking needed care from hospitals in the first place. In that regard, while Florida hospitals must also indicate that the patient’s responses will not result in a report to immigration authorities, the Texas Executive Order is silent on this point.

The Center for Healthcare Payment & Quality Reform (CHPQR) reports that over 100 rural hospitals have closed during the past 10 years. Rural hospitals in the Midwest and southern states are particularly at risk of immediate closure. The end result is that millions of people living in rural areas will be without access to more specialized inpatient and outpatient care. And it is not just the patients themselves who are impacted; family members will have to travel up to two hours to visit or accompany them to appointments. Myriad reasons contribute to these hospitals’ financial challenges, including trouble recruiting and retaining sufficient qualified staff for certain service lines; ceasing to receive extra federal assistance that was available during the COVID pandemic; receiving insufficient payor reimbursement to cover the larger overhead costs experienced by rural hospitals; and lacking sufficient financial reserves to ride out economic downturns.

CMS’s proposed annual hospital outpatient and ASC reimbursement rate schedule was published in July. This year’s proposed rule includes initiatives to address disparities in care. Among the proposals are requiring 12 months of continuous eligibility for children enrolled in Medicaid/CHIP; expanding the hospital outpatient, rural emergency hospital, and ASC quality program measure sets to incorporate equity measures consistent with other provider types; and providing an add-on payment to the All-Inclusive Rate for certain Indian Health Service (IHS)/tribal facilities that will increase access to certain high-cost drugs; and supporting individuals returning to the community from incarceration through the elimination of Medicare enrollment barriers.

New University of Southern California (USC) School of Medicine and Los Angeles County Department of Public Health joint research indicates, unsurprisingly, that areas of LA County with the highest reported COVID case rates also experience a corresponding higher incidence of depression. By some accounts, just as unsurprising was data indicating that in areas more afflicted with COVID, non-Whites incurred an increased risk of depression compared to Whites residing in those same locations.

In 2022, California announced its plans to revamp the Medi-Cal program into one that would be more equitable, focused on the individual and improved coordination among available providers and services. The two hallmarks of the effort are the Enhanced Care Management (ECM) and Community Supports programs. Earlier this year, ECM was expanded to include “justice-involved” individuals and Medi-Cal launched the ECM Birth Equity Population of Focus (POF). As of 2024, every county in the state will have at least 8 Medi-Cal managed care program (MCP) sponsored Community Supports at their disposal and 19 counties will have all 14 Community Supports, in both instances a notable increase from 2023.

The Centers for Medicare and Medicaid Services (CMS), through its FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule, issued policies aimed at furthering the Biden Administration’s goal to improve the health of communities historically underserved and lacking vital resources, as well as incentivizing value based care. By employing social determinants of health (SDOH) in making policy-related decisions, CMS is able to fine tune its allocation of resources to target those individuals most in need of improved access to equitably delivered care. One such development includes enhanced reimbursement for hospitals treating patients facing housing insecurity. Another CMS measure is to extend a separate payment to small independent hospitals–many of which are rural–that establish and maintain access to a buffer stock of essential medicines, thereby helping to lessen the risk of drug shortages and improve patient care. In addition, both LTCHs and certain qualifying general acute care hospitals will receive broad reimbursement hikes under their respective prospective payment systems.

On June 13, the U.S. Supreme Court released its decision in FDA v. Alliance for Hippocratic Medicine, overturning the opinions of the lower federal courts in the case that ruled mifepristone was unsafe. Since it was first approved by the FDA in 2000, mifepristone, commonly used in combination with misoprostol, is a widely accepted and commonly used oral abortion medication. As expected, the Court’s decision has either been heralded or lamented, depending upon which side of the abortion aisle one sits.