Legislative Action Bridging Public Health and Clinical Healthcare

January 12, 2024 | Ashley Cram, Brianna Gorman

One of the tenets of public health is ensuring equitable access to care, meaning the services needed for someone to be healthy and well are affordable and available. ASTHO’s recent analysis of State Health Improvement Plans and Strategic Plans indicates that providing and maintaining adequate access to care remains a priority across states and territories. Nevertheless, gaps in access to care persist, with many communities facing healthcare workforce shortages or facility shortages limiting the availability of care providers that can provide medically necessary services to those in need.

The State Primary Care Offices, in collaboration with HRSA’s Shortage Designation Branch, within its Bureau of Health Workforce, monitor shortages and assess needs to improve access to services. Additionally, as of August 2023, 25.3 million Americans do not have health insurance and likely face economic barriers to getting it. Three ways policymakers are addressing access to care are through telehealth, safety net and emergency services, and adjusted reimbursement rates to Medicaid-enrolled providers.

Telehealth and Supporting Infrastructure

Telehealth improves delivery of health services to rural populations and others who may have trouble accessing in-person care. In 2023, several states enacted policies expanding access to telehealth among providers and patients, such as by requiring insurance coverage of certain telehealth modalities (e.g., audio only), investing in infrastructure for these services (e.g., broadband), and authorizing participation in interstate licensure compacts that expand the pool of providers who are accessible virtually.

• Florida (HB 267) revised the definition of telehealth to include audio-only telephone calls, ensuring access to care in communities that lack broadband.
• Maryland (SB 534) extended the inclusion of audio-only telephone in the state’s definition of telehealth and required Medicaid and other health insurance plans to reimburse for telehealth services on the same basis and rate as if that service were delivered in person (not including facility fees) through June 2025. Additionally, the bill directs the Maryland Health Care Commission to assess the cost effectiveness and efficacy of telehealth-delivered services and submit a report to the General Assembly by December 1, 2024.
• Broadband is a critical component of whether patients and providers can engage in certain telehealth modalities. Texas (HB 9) established the Broadband Infrastructure Fund, increasing broadband access in economically vulnerable communities by providing matching funds to Broadband Equity Access and Deployment Program (BEAD) recipients, contingent on Texas voters ratifying Proposition 8 during the November 2023 election. With nearly 70% of the vote, the measure passed; HB 9 is in effect as of January 1, 2024. This aligns with investments made by HRSA’s Office for the Advancement of Telehealth in Texas (as well as Alaska, Michigan, and West Virginia) to examine broadband capacity through the Telehealth Broadband Pilot Program.
• Arkansas enacted legislation authorizing state participation in three interstate licensure compacts: occupational therapy (HB 1082), counseling (HB 1181), and audiology and speech-language pathology (SB 91). Interstate licensure compacts allow mutual recognition of member state licenses, which increases the number of providers that can deliver services via telehealth, thus increasing access to care.

Access to Safety Net Services and Management of Healthcare Costs

Each state’s public health agency’s role and scope related to providing direct clinical services (e.g., vaccinations, disease screenings) depends on its governance and organizational structure and the relationship with its healthcare system. Several states passed legislation in 2023 to establish initiatives that involve state health departments in facilitating access to clinical service referral and delivery.

• Indiana (SB 4) enacted legislation to promote the effective delivery of “core public health services” by state and local health departments, including referrals to clinical care for health screenings, prenatal care, and substance use disorder treatment. The new law provides greater investment in local health agencies, with the Indiana Department of Health providing technical assistance for the provision of core public health services. Additionally, by December 31, 2024, the Indiana Department of Health will identify county level metrics to measure the delivery of core public health services.
• Indiana also enacted legislation (HB 1004) establishing a Health Care Cost Oversight Task Force that will make recommendations to the legislature on managing healthcare costs, health insurance program design, healthcare insurance market competition, and availability of value-based care models. The Office of the Secretary of Family and Social Services, Department of Health, and the Department of Insurance are required to provide data to the task force to inform their decision making.
• Maryland (HB 214) established a Commission on Public Health, which will recommend improvements to delivering foundational public health services by state and local health departments, including disease prevention and access to and linkage with clinical care. The commission must submit a report on their recommendations by December 1, 2024.
• A California bill (SB 779) revises data collection requirements for primary care clinics in an effort to collect more comprehensive data on the clinic workforce and patients’ service utilization. Beginning January 2027, all primary care clinics and intermittent clinics—community clinics operated by a licensed primary care clinic on a separate premise for less than 40 hours per week and operate outside of public health regulations—must submit annual reports on staff vacancies by position, revenue spent on workforce, and patient demographics. Patient demographics may include such characteristics as payor, disability status, ethnicity, sexual orientation and gender identity, and preferred spoken language.

Access to Emergency Department Services

Currently, more than 30% of rural hospitals are at risk of closing, and more than 100 rural hospitals have closed since 2010. As a strategy to ensure access to emergency services, CMS allows critical access hospitals and rural hospitals to convert to a Rural Emergency Hospital (REH) designation. Under this designation, REHs may continue to provide non-acute services, including emergency department services and observation care; however, there are limitations on patients’ length of stay and allowable service provision. According to the National Conference of State Legislatures, at least 10 states enacted laws in 2023 to enable REH licensure: Arkansas (HB 1127), Illinois (HB 240), Indiana (HB 1457), Iowa (SF 75), Montana (HB 312), Nevada (AB 277), New Mexico (SB 245), New York (SB 4007), Oklahoma (SB 293), and West Virginia (HB 2993).

Medicaid Approaches to Expand Access to Health Workforces

Provider reimbursement rates can offer a tool to retain Medicaid-enrolled healthcare providers in underserved communities or reflect differences in patients’ social needs. States are also considering the extent to which provider reimbursement rates can reflect the difference in patient needs across geographic areas.

• Kentucky (SJR54) directed the Department for Medicaid Services to develop a proposal to link Medicaid provider reimbursement rates with Area Deprivation Index (ADI) or similar neighborhood-level index scores, which can reflect beneficiaries’ health-related social needs and community conditions that create access challenges.
• Nevada (AB 283) authorized the state’s Department of Health and Human Services (specifically the Medicaid division) to establish a new program to provide incentive payments for Medicaid-enrolled doulas who provide services in rural areas of the state.

Lessons Learned

As states work to ensure and expand access to healthcare services, key legislative strategies have emerged:

• Supporting telehealth infrastructure and provider reimbursement.
• Evaluating public health’s role and oversight of clinical service provision and standardization of access to care metrics.
• Maintaining a strong healthcare workforce through workforce recruitment and retention programs and workforce assessments.
• Supporting system alignment and data-sharing from public health, social services, and Medicaid.

ASTHO will continue to monitor these legislative trends and support its membership in implementing policies that support equitable access to services.