The public health workforce is in the midst of a crisis, dealing with staff shortages, accelerated retirements and unfilled positions.
The current climate was exacerbated by Covid-19, but many challenges began long before 2020’s pandemic. The public health system underwent a significant contraction following the Great Recession in 2008-2009, losing more than 40,000 positions in state and local governments across the country. While some of those positions were regained with Covid-19 funds during the pandemic, recruitment, diversity and retention remain as challenges, especially for hard to fill positions in nursing and epidemiology. Public health staff report high rates of burnout due to the Covid-19 response and the political climate that resulted, including suffering symptoms of post-traumatic stress disorder. It is likely that there will be staff shortages for the foreseeable future, increased retirements, and departures to other parts of the healthcare industry competing for skills with higher compensation.
New Funding Streams Available
State and local health departments have been receiving significant amounts of one-time money, including the Centers for Disease Control and Prevention (CDC) recent allocation of $3.5 billion specifically for governmental public health efforts.
Health Resources and Services Administration (HRSA) has created a new workforce research center for public health. The AmeriCorps program has developed a specific public health component. These new initiatives were designed to build and support the workforce in governmental public health. As state and local health departments receive or apply for these various sources of workforce development funding, HMA can provide existing technical assistance and training to minimize inefficiencies and duplication of efforts that might be created by a fragmented approach across state and local units of government developing independent approaches to the utilization of WFD funds.
HMA Workforce Expertise
The public health group at Health Management Associates (HMA) is made up of more than 100 colleagues with expertise in public or population health improvement, experienced working with national, state or local organizations seeking to improve public health outcomes. If your organization is looking to improve your public health workforce efforts, it is important to utilize expertise and consolidate efforts across the country so each unit of government is not “reinventing the wheel.” HMA can help multiple organizations in developing plans and coordinating processes for recruiting, training and development of the public health workforce.
HMA understands the skills that are needed to achieve high-performing public health and accountable care. Our expertise developing workforce within safety net delivery systems and accountable care organizations involve transferrable skills for the current challenges in building and developing the public health workforce. We have expertise in recruiting and are creating new training and retraining methods to meet the needs of public health teams, accountable care organizations, graduate medical education, nursing education, learning collaboratives, online training and team simulation training. We understand the care coordination, care management and IT support systems needed to backstop the workforce and meet quality and equity goals.
Policy crossroads and the end of the public health emergency due to COVID-19
This is part of a three-part series on significant implications of the end of the Public Health Emergency (PHE).
The Biden administration has announced that the COVID-19 pandemic Public Health Emergency (PHE) declaration will expire on May 11, 2023. The end of the declaration and other changes in federal policy have significant implications for state Medicaid programs, including the end of a 6.2% increase in the regular federal medical assistance program (FMAP) matching rate for states and continuous enrollment requirements put into place early in the pandemic. This means that an estimated 4-14 million Americans, especially including women and children, will need to engage in state processes for re-certification to continue their Medicaid benefits and states will lose their enhanced matching.
While state have been planning for these changes, collectively referred to as “PHE Unwinding,” the public health implications of these shifts have received little attention. As millions of Americans lose Medicaid benefits, as a result of “PHE Unwinding,” public health departments nationwide are likely to face additional demands and pressures that are also critically important for states to consider. State public health agencies that have spent the last several years responding to the COVID-19 pandemic are now entering a new phase. During the CMS-recommended 12-month period that states have to complete their redeterminations, public health agencies may see increasing numbers of individuals who were previously eligible for Medicaid and other safety net services seeking access to public health programs. Public health officials also may be called on to address the community health impacts of the newly uninsured or those who have lost other benefits, such as enhanced Supplemental Nutrition Assistance Program (SNAP) dollars for food. Addressing challenges may require significant attention of Community Health Workers or other workforces engaged across public health and healthcare and take precedence over other public health priorities. All of this will be happening at a time when public health officials are being called on to re-imagine their infrastructure needs, including reconfiguring and modernizing their data systems.
Public health agencies planning for this immediate future may benefit by taking a systems approach to PHE unwinding and considering a few key variables in their planning—
1.The end of the PHE may rapidly increase demand for public health safety net programs.
Medicaid provides coverage for the sickest and most vulnerable. As redetermination processes leave some without insurance and other benefit programs like SNAP return to pre-pandemic coverage, historically marginalized and medically at-risk populations will be disproportionately impacted. This may result in increased demand for safety net programs usually found in public health departments that serve the under and uninsured, such as the Breast and Cervical Cancer Prevention Program (BCCP) that provides cancer screening for women, and Vaccines for Children (VFC) which provides required immunizations to school-age children who otherwise lack access. Programs such as the Women, Infants and Children (WIC) and perinatal home visiting programs that serve families with limited economic resources may also see increased numbers of eligible families. Health departments can quantify these increases by assessing their populations, estimating increases, and using their existing data to determine which communities and geographic areas are likely to exhibit the greatest needs, and then share this information with policymakers.
2.Unwinding may represent an opportunity to educate legislators and policymakers on the connection between Medicaid utilization and public health programs.
As states see decreases in federal matching for their Medicaid programs, policymakers will look for opportunities to fill gaps in the state share of operating these programs. Public health programs, which are usually run with a combination of state dollars and federal grants, are often looked at as potential sources to fill gaps in Medicaid program costs. Moreover, public health officials may be able to move upstream of these discussions by ensuring that states are maximizing the federal Medicaid match (FMAP) on any public health services that can be billed to Medicaid, including using waivers and state plan amendments to cover services such as maternal home visiting or tobacco cessation under Medicaid, thus stretching grant and state dollars further while covering more individuals. While public health has long discussed the benefits of calculating and sharing the long-term return on investment of public health services, officials may also wish to consider utilizing risk stratification strategies to identify short-term cost savings and cost avoidance to other state programs of the services offered by public health departments. At the local level, health departments are often closely involved in the delivery of services that keep children in school, adults at work, and protect people in hospitals and nursing homes from health care acquired infections. All of these services have immediate benefits to state and local economies.
3. New funding for public health infrastructure, data modernization, and workforce development represents an opportunity to drive collaboration between public health, Medicaid, and other sectors.
As a part of the American Rescue Plan, state public health agencies have received funding from CDC to strengthen their infrastructure to ensure that communities have the people, services, and systems to promote and protect public health. The grants are intended to allow states to focus on increasing the size and diversity of the public health workforce; modernize data systems; and ensure states can demonstrate the foundational capabilities of public health. CDC has affirmed its expectation that states will prioritize collaboration and organizational partnerships as part of these efforts. As state public health agencies use these federal investments to impact programs that reach priority populations and improve health outcomes, several opportunities to reach disadvantaged populations and improve their health outcomes become apparent. For example, public health agencies working collaboratively with state departments of education could lead to partnerships around school-based clinics or workforce training programs, while engaging with the private healthcare and laboratory sectors on data and disease surveillance seems promising. Health departments should start now to in preparation for the flurry of activity that will be sparked in the wake of the PHE. This might involve reaching out to potential partners or organizing town-hall-style” active listening sessions with citizens to meet people where they are and better understand the needs of the community they serve.
HMA and HMA companies will continue to analyze the public health implications of the Medicaid Unwinding and the end of the PHE. We have the depth and breadth of expertise to assist with capacity building, data collection and management, and population health analysis.
If you have questions on how HMA can support your agency before or after the end of the PHE, please contact:
Jean O’Connor, Managing Principal Morgan Wilson, Research Associate
Policy crossroads and the end of the public health emergency due to COVID-19
This is part of a three-part series on significant implications of the end of the Public Health Emergency (PHE).
What does your organization need to know?
March 31st marked the end of the COVID-19 Medicaid continuous coverage condition. Most forecasts project between 10-15 million enrollees will lose Medicaid coverage. State Medicaid programs will lose supplemental funding provided for the continuous coverage requirement and begin to transition to normal eligibility operations. Health Management Associates (HMA) and HMA companies can help the full spectrum of stakeholders plan for, adjust to, and administer the changes up to and beyond the 12-month continuous coverage “unwinding” period. The immediate work can serve as a springboard for future improvement initiatives and to respond to federal guidance that is under development to strengthen and streamline eligibility and enrollment processes and improve the experience for consumers.
Who is affected by this change?
Payers including Medicaid managed care organizations and Qualified Health Plans
Provider organizations
Trade associations of Medicaid managed care or provider organizations
State and local community-based organizations
State and local governments responsible for administering and overseeing the eligibility processes for Medicaid and other public programs
Advocacy groups
Foundations
Vendors supporting state agencies, health plans and providers
Watch a video presentation about the HMA Coverage Model
What is in the HMA model?
HMA has developed an insurance mix model that projects how the resumption of Medicaid eligibility redeterminations beginning in April 2023 will affect Medicaid enrollment, employer sponsored insurance (ESI), Marketplace coverage, and the uninsured. The model includes enrollment projections for all 50 states and considers the enhanced Marketplace subsidies included in the Inflation Reduction Act (IRA). Approximately 20 million individuals gained coverage during the redetermination freeze and well over 10 million of the approximately 90 million current Medicaid enrollees are at risk for disenrollment. HMA’s model contemplates the variety in state approaches to managing the resumption of eligibility redeterminations as well as key insights related to the differential impact by Medicaid eligibility categories.
HMA can help with immediate needs to help you plan:
HMA has detailed state-specific unwinding policy insights for each state including observations regarding which states are taking more aggressive and less aggressive approaches.
We can provide technical assistance and strategic planning services to help states and organizations manage the necessary changes.
Actuarial experts can assist with acuity changes caused by the change in enrollment.
Our colleagues are available for a discussion of the product and the key policies influencing the projections.
This week, our In Focus reviews a new Health Management Associates (HMA) report, highlighting hybrid (in-person & virtual visits) as the future of child welfare service delivery. During the COVID-19 public health emergency (PHE), the federal government waived the requirement for “once every 30 days” in-person visits by caseworkers for children in foster care, allowing these visits to occur virtually. In 2021, Casey Family Programs (CFP) commissioned HMA to evaluate the delivery of virtual child welfare services and outline the implications of the COVID-19 PHE on the child welfare system.
The report “Evaluating the Delivery of Virtual Child Welfare Services” is now available. It summarizes HMA’s findings and elevates the voices of staff in public and private child welfare agencies, and of youth and families with lived experiences, and examines their perspectives on how well virtual services have worked. It also details the implications of the COVID-19 PHE, the response from public child welfare agencies, and offers guidance on a hybrid (part in-person, part virtual) service model, which we believe will continue to be a factor in the future delivery of child welfare services.
As the COVID-19 PHE accelerated the spread and scale of telehealth adoption in health care, we surmised that the experience offered valuable opportunities to learn more about how the health care sector’s adoption of telehealth services could be applied in the child welfare community. While cognizant of the unique considerations for child welfare, this disruption also represents a substantial opportunity to rethink the child welfare system and advance both the use of technology as well as a more prevention- and strengths-based approach to child welfare.
The report highlights innovative approaches in the field, offers questions to frame a jurisdiction’s decision-making process, and provides a tool to facilitate an informed decision on the hybrid model. The report also offers a broader value proposition that outlines policy, practice, workforce, and technology imperatives to develop a hybrid approach to the delivery of child welfare services.
This week our In Focus section reviews President Joseph R. Biden’s 2023 State of the Union Address (SOTU) to Congress. The President highlighted specific actions that Congress, and the Administration have taken over the last two years to advance his health care priorities.
During his first SOTU address in 2022, President Biden announced the creation of a “Unity Agenda”, which included priority policy areas with potential for bi-partisan support. The President highlighted several steps the Administration has taken to advance the “Unity Agenda” including:
The bipartisan effort to enact the Mainstreaming Addiction Treatment (MAT) Act, which removed the federal requirement for practitioners to have a waiver (known as the X-waiver) to prescribe medications, like buprenorphine, for the treatment of opioid use disorder
The Cancer Moonshot announcements for almost 30 new programs, policies, and resources to close the screening gap, tackle environmental exposure, decrease preventable cancers, advance cutting-edge research, support patients and caregivers, and more.
Addressing mental health needs through the expansion of Certified Community Behavioral Health Clinics and launch of the 988-suicide prevention hotline.
In his SOTU and accompanying White House materials, the President also proposed new policies and initiatives to further advance his health care agenda. These actions include a combination of issues that would require Congressional approval as well as actions regulatory agencies can already advance. Congress and the Administration are expected to build on previous bipartisan achievements to tackle the nation’s dual crises with addiction and mental health.
Notably, the policies outlined in the SOTU foreshadow an active regulatory agenda over the next 18 months as the Administration seeks to solidify key aspects of the President’s health care agenda ahead of the next Presidential election.
The Administration’s planned actions include the following:
Opioids
Calling on Congress to pass legislation to permanently schedule all illicitly produced fentanyl-related substances into Schedule I.
SAMHSA will provide enhanced technical assistance to states who have existing State Opioid Response funds, and will host peer learning forums, national policy academies, and convenings with organizations distributing naloxone beginning this spring.
By this summer, the Federal Bureau of Prisons will ensure that each of their 122 facilities are equipped and trained to provide in-house medication-assisted treatment (MAT).
This spring CMS will provide guidance to states on the use of federal Medicaid funding to provide health care services—including treatment for people with substance use disorder—to individuals in state and local jails and prisons prior to their release. California is the first state to receive approval for a similar initiative.
Mental Health
CDC plans to launch a new campaign to provide a hub of mental health and resiliency resources to health care organizations in better supporting their workforce.
The Department of Education (ED) will announce more than $280 million in grants to increase the number of mental health care professionals in high-need districts and strengthen the school-based mental health profession pipeline.
HHS and ED will issue guidance and propose a rule to make it easier for schools to provide health care to students and more easily bill Medicaid for these services.
The Administration is scheduled to propose new mental health parity rules this spring.
HHS will improve the capacity of the 988 Lifeline by investing in an expansion of the crisis care workforce; scaling mobile crisis intervention services; and developing additional guidance on best practices in crisis response.
HHS also plans to promote interstate license reciprocity for delivery of mental health services across state lines.
HHS intends to increase funding to recruit future mental health professionals from Historically Black Colleges and Universities and to expand the Minority Fellowship Program.
The Department of Veterans Affairs (VA), working with HHS and Defense, will launch a program for states, territories, Tribes and Tribal organizations to develop and implement proposals to reduce suicides in the military and among veterans.
VA will also increase the number of peer specialists working across VA medical centers to meet mental health needs
Cancer Moonshot
The President called on Congress to reauthorize the National Cancer Act to overhaul cancer research and to extend the funding for biomedical research established in the 21st Century Cures Act.
The Administration will take steps to ensure that patient navigation services are covered by insurance. This could require legislation depending on which type on insurance an individual has.
Health care costs
Urging Congress to pass legislation to cap insulin prices in all health care markets. Expanding the $35 insulin cap to commercial markets will require the 60 votes in the Senate.
Home and community services
Working with Congress to approve legislation to ensure seniors and people with disabilities can access home care services and to provide support to caregivers.
HMA and HMA companies are closely monitoring these federal policy developments. We can assist healthcare stakeholders in responding to the immediate opportunities and challenges that arise and contextualize these actions for longer-term strategic business and operational decisions.
If you have questions about these or other federal policy issues and how they will impact your organization please contact Andrea Maresca ([email protected]) or Liz Wroe ([email protected]).
Join us on Monday, March 6, 2023, at the Fairmont Chicago, Millennium Park, for “Healthcare Quality Conference: A Deep Dive on What’s Next for Providers, Payers, and Policymakers,” where Lee Fleisher, MD, chief medical officer and director of CMS’ Center for Clinical Standards and Quality, will deliver the keynote titled A Vision for Healthcare Quality: How Policy Can Drive Improved Outcomes.
HMA’s first annual quality conference will provide organizations the opportunity to “Focus on Quality to Improve Patients’ Lives.” Attendees will hear from industry leaders and policy makers about evolving health care quality initiatives and participate in substantive workshops where they will learn about and discuss solutions that are using quality frameworks to create a more equitable health system.
In addition to Fleisher, featured speakers will executives from ANCOR, CareOregon, Commonwealth Care Alliance, Council on Quality and Leadership, Intermountain Healthcare, NCQA, Reema Health, Kaiser Permanente, United Hospital Fund, and others.
Working sessions will provide expert-led discussions about how quality is driving federal and state policy, behavioral health integration, approaches to improving equity and measuring the social determinants of health, integration of disability support services, stronger Medicaid core measures, strategies for Medicare Star Ratings, value-based payments, and digital measures and measurement tools. Speakers will provide case studies and innovative approaches to ensuring quality efforts result in lasting improvements in health outcomes.
“What’s different about this conference is that participants will engage in working sessions that provide healthcare executives tools and models for directly impacting quality at their organizations,” said Carl Mercurio, Principal and Publisher, HMA Information Services.
View the Full Agenda
Early Bird registration ends January 30. Visit the conference website for complete details or contact Carl Mercurio at 212-575-5929/[email protected]. Group rates and sponsorships are available.
In 2022, HMA convened stakeholder roundtables in three states – including New Mexico, North Dakota, and Tennessee to identify the challenges facing dually eligible individuals living in rural areas and to propose solutions to these challenges. Informed by this process, HMA developed the Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit.
The toolkit is structured around three domains used to organize eight solutions. For each solution, HMA provides a description of the rural access challenge, the proposed solution, and the proposed tool. Each tool is powered by some type of lever available to the federal and state government. We anticipate that policymakers will build upon this toolkit through continued dialogue with rural communities. The toolkit’s framework, goals, and actionable solutions are summarized in the figure below.
HMA Principal Ellen Breslin, Consultant Samantha Di Paola, and Senior Consultant Susan McGeehan authored the toolkit, with research contributions from HMA Principals Rebecca Kellenberg and Andrea Maresca.
On February 2, 2023, 1pm ET, HMA will host a webinar on the HEARD toolkit. During this webinar, HMA experts and panelists including Dr. Kevin Bennett (USC-SOM Columbia, SC CRPH), Dennis Heaphy (DPC), Pam Parker (SNP Alliance), and Tallie Tolen (New Mexico Medicaid) will summarize and discuss the toolkit’s actionable solutions for improving rural dually eligible individuals’ health and social outcomes.
As respiratory syncytial virus (RSV), a seasonal pathogen in young children is challenging the national health care system as part of an unprecedented “tripledemic” with COVID-19 and flu this winter, HMA authors weigh in on potential coverage pathways for new monoclonal antibody (mAb) preventive therapies for RSV and their implications for access.
The Vaccines for Children (VFC) program is a proven vehicle for ensuring comprehensive coverage of immunizations based on recommendations from the Advisory Committee on Immunization Practices (ACIP). An ACIP workgroup is actively discussing potential recommendations for immunization with RSV mAbs.
In the recent Health Affairs Forefront article, “Coverage By Vaccines For Children Program Is Critical For RSV Therapy Access,” HMA authors Helen DuPlessis, MD, FAAP, Diana Rodin, and Matt Wimmer explore the implications of ACIP recommendations, Medicaid coverage pathways, and children’s access to the new therapies.
This week, our In Focus section reviews changes to Medicaid’s COVID-19 Public Health Emergency (PHE) unwinding. People enrolled in the Medicaid program have been continuously enrolled for almost three years, but that situation is about to change. In December 2022, Congress passed and the President signed into law a massive compromise bill to fund the government. It includes an important change to Medicaid’s continuous enrollment policy, which has been in effect since the early days of the COVID-19 PHE in March 2020.
Congress passed the Families First Coronavirus Relief Act (FFCRA) in March 2020. This legislation has allowed states to receive a 6.2 percentage point increase in their federal matching rate for Medicaid. As a condition for receiving the enhanced funding, states have been prohibited from disenrolling individuals who were otherwise determined ineligible for Medicaid. As a result, nearly 20 million more people are now enrolled in the Medicaid program.
The 2023 spending bill severs the link between the COVID-19 PHE declaration, the continuous enrollment requirement, and the higher federal match rate. The new law:
Ends the Medicaid continuous coverage policy on March 31, 2023, even if the PHE declaration remains in effect. States may begin issuing terminations of ineligible individuals as early as February 1, with an effective date of April 1.
Phases down the 6.2 percentage point increase in the federal matching rate rather than ending it abruptly at the end of the PHE as required under the FFCRA. Specifically, the increase will drop to 5 percentage points in April−June 2023, 2.5 percentage points in July−September 2023, and 1.5 percentage points in October−December 2023.
Does not end the PHE or other flexibilities linked to the PHE.
Congress also added new parameters and reporting requirements for states as they resume annual eligibility renewals with coverage cancellation for individuals who no longer qualify. These requirements are in addition to data the Centers for Medicare & Medicaid Services (CMS) previously directed states to report. For example:
States must maintain up-to-date enrollee contact information for individuals who will undergo an eligibility redetermination.
States cannot disenroll individuals based only on returned mail.
Prior to disenrolling an individual, the state must make a “good faith effort” to contact the person using more than one communication mode.
States must submit to CMS “on a timely basis” a report explaining their eligibility redetermination activities.
States must submit data related to individuals whose eligibility information was transferred between Medicaid and the Marketplace, with some exceptions for states that have integrated Medicaid and Marketplace eligibility systems and those that use the Federally Facilitated Marketplace.
Beyond the “Delinking”
The new law includes other important eligibility-related policies that may affect state and stakeholder planning for what is often referred to as the “unwinding” of continuous enrollment. Notably, the state Medicaid and CHIP programs will now be required to provide 12 months of continuous coverage for children. A total of 24 states already have adopted the 12-month continuous eligibility option for all children enrolled in Medicaid. While the new requirement will not take effect until January 1, 2024, additional states could adopt this option as they resume normal eligibility operations.
In addition, the new law makes permanent the option for states to extend Medicaid postpartum coverage to 12 months, up from 60 days. The one-year postpartum coverage option initially was approved in the American Rescue Plan but for a limited period of five years. Making the option permanent provides more certainty for states. Nearly two-thirds of states have already implemented or are planning to implement the 12-month postpartum coverage extension.
What Happens Next?
The definitive end date for the continuous enrollment policy sets in motion certain federal and state actions and the process for unwinding. On January 5, 2023, CMS published its first guidance to states on processes related to the new unwinding date. The agency is developing additional guidance and will use other communication tools to provide states with greater clarity on the new statutory reporting, matching rate, and federal agency expectations and oversight.
State plans: All states must submit unwinding plans to CMS by February 15; however, February 1 is the deadline for states that intend to begin renewals in February. These proposals must provide details regarding unwinding strategies, the timeline for starting enrollee renewals, and the pace of ongoing renewal processes. The specific end date for the continuous enrollment policy is driving more states to review and finalize their initiatives and engage with stakeholders.
Impact on health plans and providers: The unwinding process will create important decision points and considerations for Medicaid health plans and providers that have members and patients whom the unwinding process may affect in the next 12-18 months. The law’s requirements reinforce the imperative for states, Medicaid health plans, providers, and other partners to renew efforts to confirm enrollee contact information. The unwinding all will create new considerations for Medicaid health plans with respect to enrollee support, case mix, and rate setting issues.
State budgets and legislation: Many states will kick off their legislative sessions this month. The unwinding process—especially the phase-out of higher federal funding—has important implications for state budgets. State legislatures also may address the new continuous eligibility requirements for children and the permanent option for 12 months of postpartum coverage. As a result, Medicaid will likely remain a top priority during upcoming legislative sessions.
Federal oversight and enforcement: The law’s enhanced reporting provision is intended to provide safeguards to ensure eligible individuals remain enrolled in Medicaid. The reporting also focuses on data related to identifying and directing individuals likely to be eligible for the Marketplace program. Although CMS must publicly report these data, the agency has offered no specific timeline for posting the information. Notably CMS has oversight tools and may impose financial penalties on states that are noncompliant with the unwinding requirements.
Forthcoming federal guidance will confirm the parameters for state unwinding actions, CMS’s plans for oversight of state work, and how these efforts affect current Medicaid enrollees. Medicaid partners should closely monitor state level actions, including announcement of state unwinding plans and opportunities for collaboration. Earlier blogs describe the strategies and actions HMA is working with states and partners to undertake as they prepare for this significant change in Medicaid eligibility policies.
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). Dually eligible individuals residing in rural areas represent about 5 percent of all rural residents. They reside at the intersection of a public health crisis and a fragmented Medicaid and Medicare care delivery system. As HMA wrote in Health Affairs, this small population is at risk of falling through the cracks of this crisis and suffering a steep rural mortality penalty.
With support from Arnold Ventures, HMA prepared “The Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit: Raising Rural Voices from New Mexico, North Dakota, and Tennessee to Create Action. The toolkit contains eight actionable solutions for federal and state policymakers to use and tailor to states’ needs. Ellen Breslin, Samantha Di Paola, and Susan McGeehan authored the toolkit, with research contributions from Rebecca Kellenberg and Andrea Maresca. The toolkit is available here.
