Three Areas Where a Biden Administration Can Have an Immediate Impact on Inequality

COVID-19 has taught us all a powerful lesson: government assistance matters. When it is direct and not funneled through the hoops of means-testing and justification of vulnerability and need, it is the primary tool that can help meet the American people’s necessities and maintain economic activity. As the Biden Administration pursues a policy agenda to reverse the trends of elevated poverty, stagnating wages, and increasing racial inequality, this will continue to be the case.

Impacts of the pandemic have exposed how close to the edge many Americans live. At the same time, the stress of millions of people seeking help is pushing our country’s safety net systems to the edge. Based on our experience helping states and counties turn adopted policy into functioning systems that help people, and our observations of the practices that have produced good results, we’re submitting the following recommendations. During this unprecedented convergence of public health, social, and economic crises, these recommendations would allow the US Department of Agriculture (USDA) and the US Department of Health and Human Services (HHS) to immediately allow their systems to provide critical government assistance, work efficiently and effectively, and eliminate barriers to getting help to those who need it.

ADVANCE INTEROPERABILITY

Ten years ago, the Affordable Care Act (ACA) became bedrock legislation ensuring greater access to health for all, and there’s still unfinished business to help it realize its promise of addressing health equity. One area that the Biden Administration can address quickly to make progress on this front is interoperability. “Interoperability” is the ability of systems to interact with each other to share data so that people can be connected to as many benefits as possible in an efficient way. The original vision was that the ACA would not only connect people to healthcare coverage, it would also help people connect with the range of supports available that improve a person’s life, including food support. Section 1561 of the ACA gives specific direction to develop interoperability between the health exchanges and enrollment, and health and human services programs. This can be achieved by taking eight steps:

1. Re-issue A-87 OMB Circular
2. Reinstate enhanced federal funding for both Medicaid and FNS (Food and Nutrition Services) systems to meet the 7 Conditions and Standards
3. Issue formal regulations based on ONC Health IT’s recommendations for Section 1561 of the ACA. Specifically, an ideal HHS eligibility and enrollment process:
     • Features a transparent, understandable, and easy to use online process that enables consumers to make informed decisions about applying for and managing benefits;
     • Accommodates the range of user capabilities, languages, and access considerations;
     • Offers seamless integration between private and public insurance options;
     • Connects consumers not only to health coverage but also to other human services such as the Supplemental Nutrition Assistance Program (SNAP) and the Temporary Assistance for Needy Families (TANF) program; and
     • Provides strong privacy and security protections.
4. Provide enhanced federal funding for administrative costs related to modernizing service delivery design and customer service. See, e.g., Tackling Challenges Amplified by COVID-19: Best Practices for State and County Social Safety Net Agencies.
5. Incentivize states to have HHS agencies partner with state unemployment and state public health departments to promote cross-enrollment rather than simple referrals. Share best practices.
6. Issue joint guidance to clarify requirements for data sharing between FNS (Food and Nutrition Services) and CMS (Center for Medicaid Services).
7. Provide a template for an HHS-wide MOU for data sharing. (See CA’s Data Playbook).
8. Conduct audit/analysis of total federal dollars spent on verification through the use of private-sector vendors such as Equifax (e.g., Work Number) and require more transparency in these contracts.

IMPROVE ELIGIBILITY AND ENROLLMENT

Promoting interoperability will provide a simple way to improve eligibility and enrollment processes that get coverage for almost all of the estimated 28 million Americans who are largely made up of: working people (73%); and communities of color (59%). It also allows for the harmonizing of income eligibility that would enable government agencies, hospitals, insurers, and other organizations to use one application to determine a person’s eligibility for many programs, and initiate automatic enrollment when appropriate.

Currently, when a person logs into the health care exchange system, their eligibility for either subsidized private insurance exchanges or Medicaid is determined. Leveraging an interoperability approach would encourage improvements in eligibility and enrollment that would ensure if someone is found eligible for Medicaid or a health exchange subsidy, their eligibility for SNAP, WIC (Women Infants and Children), TANF, and other support programs would also be completed. Once a person is considered eligible for a program, implementing the following eight (8) recommendations will allow for a system that can start cross-enrollment automatically.

1. Issue regulation for clear acceptance of telephonic and electronic signatures as federal requirements for CMS and FNS, rather than via guidance, state option/waivers. Provide clearer guidance to states on acceptance of telephonic/electronic signatures, especially for ALL forms, not just initial applications.
2. Align Medicaid/SNAP policies for countable income and resources and verification requirements for residency, immigration status, and identity documentation.
3. Provide joint guidance on the use of Federal Data Services Hub for verification of non- income data. (Currently, states must individually seek authorization from Social Security Administration (SSA) for SNAP/TANF agencies to have access to the SSA database).
4. Provide states clear guidance on countable income and verification needed for gig economy workers (who do not easily fall into the seasonal worker rules). Review current practices of states.
5. Remove the requirement to record telephonic signature for SNAP via audio file and align with CMS’ provisions for telephonic signature (allowing, but not requiring, audio file and allowing case notes).
6. FNS should require states to conduct an ex-parte review process for recertification of SNAP (rather than requiring complete re-application) and require states to align annual recertification dates for families on both programs.
7. Issue guidance to encourage states to actively use policy linkages between Medicaid, SNAP, and TANF per existing federal regulations.
8. Contribute to addressing the digital divide by encouraging states to help with SNAP and Medicaid recipients’ auto-enrollment to Lifeline per existing federal regulations

USE FEDERAL CONTRACTING AND GRANTMAKING CLOUT

Even with encouraging interoperability and improvements to eligibility and enrollment, a good deal of the federal guidance around grantmaking, procurement, and contracting support states and counties continued use of approaches that are firmly lodged in problematic methods. These include methods that do not fairly distribute resources, or take a big-picture view of associated implications and goals. This approach results in long timelines, poor definition of buying requirements, ineffective supplier performance management, an inability to adapt to the needs of communities receiving support or the agency staff providing it, and a lack of transparency. Notably, these practices contribute to granting, buying, and contracting inequities. In this time of crisis, federal procurement cannot afford a lack of transparency, a lack of diversity of vendors, or a lack of realistic goals or timelines for the work. For the government to fairly make grants, procure, and contract for services that will make a real impact and bring new thinking and approaches, implementing the below eight recommendations will respond to short-term needs while allowing for planning for the long-term.

1. Provide grants and contracts to public hospitals, Medicaid providers, FQHCs (federally qualified health centers), and community clinics to increase their ability to manage trust and safety among people and employees by leveraging digital technologies.
2. Require any new IT contracts for vendors to work directly with affected communities as part of the design and development process, not just for user testing.
3. Encourage states to award contracts submitted by collaborations rather than single vendors with subcontractors.
4. Issue an executive order expand on CARES Act requirement that the Government Accountability Office (GAO) to issue bi-monthly reports on the impact of COVID-19 to track all HHS and USDA grants and contracts by race, sex, and other categories
5. Add implementation guidance to Preparedness and Response Supplemental Appropriations Act (P.L. 116-123) to encourage use of vaccination sites for outreach and education for Medicaid, SNAP, UI (Unemployment Insurance), and other services.
6. Establish procurement and contracting equity policies and programs within CMS and FNS funding programs based on an analysis of the specific barriers faced by people of color, women, and non-profit business enterprises in a specific geographic target.
7. Establish incentives and goals for a minimum percent of federal funds to be awarded to people of color, women, and non-profits.
8. Give preference to a collaboration of vendors and avoid sole-source contracts.