NASHP brought together its largest group for this year’s annual conference, with more than 1,000 state health policy leaders, policymakers and policy experts from across the country attending in Nashville earlier this month. This year’s conference was themed “Amplifying Sound Health Policy,” and, as usual, the conference covered a range of health policy topics, starting with “pre-conference” panels on aging, cost drivers, and workforce sustainability. During the main conference, key topics covered included health-related social need and justice-involved waivers, health equity, maternal, prenatal and pediatric health, behavioral health, public health, and effective engagement and partnerships across state agencies and with stakeholders. 

Artificial Intelligence (AI) 

Day two of the conference started with a panel on the role of AI in healthcare – both the provision of healthcare services and eligibility and enrollment in coverage. Paige Nong, Assistant Professor from the University of Minnesota, spoke about the role, promise and challenges in the use of AI in the delivery of healthcare. She shared examples of its recent uses and promises, but also stories of challenges with accuracy, including when the tool hasn’t been adapted for the particular population to which it is being applied. Micky Tripathi, Assistant Secretary for Technology from the Department of Health and Human Services, and Senator Bo Watson from Tennessee, and member of the Tennessee AI Advisory Council, spoke to the role of policymakers to both promote AI and provide guardrails for its use.  

Jessica Altman, Executive Director of Covered California, spoke to the emerging role of AI in eligibility and enrollment. Much of her focus was guardrails she feels are important to have in place when engaging AI to support processes. Altman noted the importance of not just handing decisions over to technology. The public should feel assured that humans will remain engaged in the process, as a backstop to ensure accurate determinations are made. She also noted that AI should be used to supplement and most effectively utilize staff, not to replace a staffing model. For example, if a leaner staff is needed for application processing with the use of AI, other staff can be allocated to making outgoing calls regarding redeterminations. 

All speakers underscored the importance of everyone engaged in health policy taking time to learn about and better understand AI – its promises and challenges. This is not a topic that should be delegated to IT teams – everyone should be involved in considering its role in healthcare and coverage going forward. 

Strengthening Systems to Support Justice-Involved Youth 

NASHP also featured a session focused on state strategies to provide reentry services to children and youth, featuring speakers from Washington and Arizona. Since 2022, 11 states have received approval from the Centers for Medicare and Medicaid Services (CMS) to provide reentry services under 1115 Demonstration Waivers. Beginning January 1, 2025, all states will be required to provide certain reentry State Plan services to children and youth as they transition back to their homes and communities. Panel speakers included Tyron Nixon, Washington Medicaid’s Reentry Transformation Implementation Manager; Ted Ryle, Clinical Director for Washington’s Department of Children, Youth & Families – Juvenile Rehabilitation; and Alex Ruth, Program Administrator for the Arizona Health Care Cost Containment System’s (AHCCCS) Justice Initiatives. 

Washington received approval for its 1115 Reentry Demonstration Waiver in 2023, which has allowed the state to continue existing work and develop additional services and supports for individuals reentering their communities. Over the past several years, the state has worked to build internal infrastructure and capacity to increase access to medications for opioid use disorder (MOUD) for people who are incarcerated and develop continuity of care systems with community providers who can continue treatment for individuals upon release. The state has invested in, and relies heavily upon, interagency and inter-organizational partnerships, particularly around streamlining Medicaid enrollment and suspension processes and engaging community-based providers. Speakers from the state reiterated that it has been these partnerships, in addition to the commitment of the Governor and legislature to support these communities, that has gotten Washington to where it is today.  

Although Arizona has not yet received approval of its pending 1115 Reentry Demonstration Waiver application, the state has developed infrastructure and systems to support individuals transitioning in and out of incarceration, including pre- and post-release service. Using automated, bidirectional data exchange agreements, AHCCCS coordinates with county jails and the Arizona Department of Corrections, Rehabilitation and Reentry to suspend Medicaid coverage for incarcerated adults upon entry and reinstate upon release. The state is moving towards a similar automated process for young people who are incarcerated. Each AHCCCS contracted health plan also has a dedicated justice system liaison and court coordinator, who help to coordinate and facilitate prerelease activities and connections to care. With the upcoming requirement to provide certain reentry services to youth, Arizona has compared what it already covers with what is required under the Consolidated Appropriations Act so that it can prioritize its funds and resources and ensure compliance ahead of program implementation. 

In its July State Health Official letter, CMS indicated that it would be publishing a State Plan amendment template for states to use as they build out their reentry services for youth. As of the time of publication of this article, CMS has not yet released its template for re-entry State Plan amendments. Health Policy News will continue to track this issue. 

State Efforts to Ensure Access to Care in Rural Communities 

On the final day of the conference, NASHP hosted a panel session on the unique challenges that states face in ensuring access to quality care for their rural populations. In a session facilitated by Jimmy Blanton, the Deputy Director of Quality and Improvement at Texas Medicaid/CHIP, rural health veterans Dr. Lauren Hughes, Sate Policy director of the Farley Health Policy Center and former Deputy Secretary for Health Innovation in the Pennsylvania Department of Health, and Brock Slabac, Chief Operations Officer of the National Rural Health Association and seasoned rural hospital administrator, found common ground on the obstacles faced by health care providers and patients in rural areas. Of particular focus were funding streams that stabilize community hospitals, the variability of telehealth adoption, and the outsized role that community organizations and businesses play in shaping community health in rural areas as compared to their urban counterparts. 

Mr. Blanton opened the session with a review of the deep and often intractable health challenges in rural Texas – primary care shortages, hospital closures, public payer mix concentration, workforce challenges, Health Related Social Needs, and how all these factors contribute to poor access and quality outcomes. Dr. Hughes detailed the Pennsylvania Rural Health Model – authorized under Section 3021 of the Affordable Care Act – which seeks to test whether care delivery transformation in conjunction with hospital global budgets increase rural Pennsylvanians’ access to high-quality care and improve their health, while also reducing the growth of hospital expenditures across payers, including Medicare, and improving the financial viability of rural Pennsylvania hospitals to improve health outcomes of and maintain continued access to care for Pennsylvania’s rural residents. In its final year, the model is at a crossroads, and state policymakers are working on figuring out the next generation model. While most of the 18 participating hospitals entered into two-year transition agreements that will enable them to continue receiving the innovation payments, managed care and commercial payers will revert to traditional fee-for-service payments. 

Mr. Slabach focused on the national trend of rural hospital closures and highlighted the role of the Rural Emergency Hospital (REH) designation created under the Consolidated Appropriations Act of 2021. REH designation allows rural hospitals to maintain outpatient and emergency department payment from Medicare without a requirement of (and actually prohibits) inpatient acute care services. REHs may provide observation level of care, telehealth, ambulance, and skilled nursing facility services. Among other core requirements, REHs must maintain transfer agreements with a level I/II trauma center and meet the licensure requirements and staffing levels of an emergency department. By some analyses, the REH model has been effective at preventing certain rural hospital closures. 

On the topic of quality improvement, the panel addressed questions about strategies to advance access and quality in underserved communities. They focused on parsimoniousness and relevance in quality measurement – for example leveraging National Quality Forum’s Rural Measures Set – and creative collaboration with a broad set of non-traditional care providers (e.g. community health workers) and community stakeholders that play important roles in the daily lives, such as banks, businesses, grocers, and schools. One panelist argued that rural hospital leaders need to recast their role as community organizer.