Congressional Social Determinants of Health Caucus – Request for Information

Families USA, a leading national, non-partisan voice for health care consumers, dedicated to achieving high-quality, affordable health care and improved health for all, welcomes the formation of the bipartisan Congressional Social Determinants of Health (SDOH) Caucus. We are pleased to submit these comments in response to your request for information on opportunities to improve health outcomes and to maximize existing and future federal investments in social drivers of health. And as an organization that views health equity among the true cornerstones of the American health care system, we look forward to partnering with you as you continue exploring ways to better support and coordinate services aimed to address social determinants of health for all.

In addition to specific feedback on some of the questions included in your request for information, we also offer additional background on ways that Families USA can be in service to your mission. Our ability to engage a broad network of stakeholders representing diverse constituencies including consumers, business and employers, labor, providers, insurers, and other key players in the health care sector is the hallmark of our success – as is our history of working with leaders from both sides of the aisle to tackle the health care problems facing the nation.

We have deep, longstanding relationships with a diverse group of consumer leaders, advocates, and partner organizations in all 50 states and Washington, D.C. which enable us to address both state and national policy challenges. One relevant example is our recent report in collaboration with the California Pan-Ethnic Health Network (CPEHN) and other California stakeholders that advocate for comprehensive recommendations around health equity ranging from conventional health policy interventions to more fundamental social and health workforce reforms.[1]

We regularly convene fellows to participate in our Health Equity Academy to build and train a corps of health equity advocates who can effectively participate in discussions and decision-making about pressing policy issues.  More broadly, Families USA partners with national and state health equity advocates through the Health Equity Task Force for Delivery & Payment Transformation to advance our policy agenda centered on rectifying health inequities and developing strategies and tactics that are broader in appeal and impact, including building and participating in larger coalitions.

With respect to the COVID-19 pandemic, our work has centered on promoting equitable vaccine distribution and access. In addition to our April 2021 report summarizing early findings from state and local partners tasked with administering vaccine doses to their communities, we also established a COVID-19 Vaccine Equity Learning Collaborative consisting primarily of state/local advocates and community-based organizations working to improve vaccine equity policy in their states. This group meets monthly to discuss pressing issues in the vaccine equity space, provide a platform for those working on issues to share their experiences and create a space for advocates to share best practices with one another in order to secure long term health equity policy changes.

As you continue to develop your policy agenda and plan future activities through the caucus, we hope you will consider us as a strong partner and resource for your work. As a first step, please find responses to your request for information below.

Experience with SDOH Challenges

What specific SDOH challenges have you seen to have the most impact on health? What areas have changed most during the COVID-19 pandemic?

The mass COVID-19 vaccination effort is a timely example of the devastating impact SDOH challenges can have on public health, as it has been fraught with inequities with respect to access and distribution. Even as supplies have increased, the pattern across virtually every state is consistent: Black and Hispanic people continue to get fewer vaccine shares relative to the COVID-19 death and illness they experience.[2] A vaccination strategy that is fundamentally aimed at reducing death and illness from COVID-19 must intentionally focus on effective vaccination of populations of color.

As you know, SDOH are not mutually exclusive to one another, with the presence of one determinant often exacerbating others. For example, because health insurance coverage is often tied to employment and overall income level, economic/financial insecurity can have a huge impact on access to care as demonstrated by recent layoffs or other shutdowns of companies in the restaurant and service sectors that left millions of employees in flux. Over the past 18 months, we’ve also seen significant spikes in those experiencing housing insecurity as a compounding result of widespread loss of employment. As eviction and mortgage payment moratoriums expire throughout the country, millions are at higher risk than ever of experiencing homelessness, which has important consequences on overall health status in terms of the lack of reliable access to medical and social services. Housing insecurity in turn tends to lead to food insecurity, which affects children particularly hard, as school closures and virtual learning restricts the availability of healthy school meals.

It is also important to recognize that the dominance of fee-for-service (FFS) reimbursement models among primary care, behavioral health, and other sectors destabilized the health care system in 2020 and, more broadly, limits incentives to address SDOH in the health care system. As detailed below, greater adoption of alternative payment models will require fundamental reforms in how all payers, including Medicare, are reimbursed for health care: instead of delivering units of service while omitting SDOH needs, we must move towards prospective, population-based payments that grant providers the financial latitude to meet all patient population needs. We recommend several Congressional actions to support this goal in our subsequent responses to this RFI.

What types of gaps in care, programs, and services serve as a main barrier in addressing SDOH in the communities you serve? What approaches have your organization, community, Tribal organization, or state taken to address such challenges?

Through the Build Back Better Act, Congress has a critical opportunity to knock down a variety of barriers to addressing SDOH by increasing federal investment in social services, early childhood education, child care, economic opportunity, health care, environmental pollution, and preventing incarceration.

We also see the Medicaid coverage gap as a threshold barrier to progress on SDOH. Over 2.2 million people in the 12 states that have yet to implement full Medicaid expansion–60% of whom are people of color–earn too much to qualify for their state’s Medicaid program but not enough to qualify for Marketplace subsidies.[3] These states’ refusal to expand Medicaid further exacerbates longstanding health inequities: some people with incomes below the poverty line have access to health care, while others do not. In expansion states, the availability of Medicaid coverage has decreased cancer deaths, poverty rates, and evictions. Comprehensive health insurance and all of the health and economic benefits associated with it are currently unavailable to people who could and should be eligible for coverage in Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

Are there other federal policies that present challenges to addressing SDOH?

There are numerous federal policies that currently present challenges to addressing SDOH, as you will see highlighted throughout our responses and in those provided by our stakeholder partner organizations. One specific issue we want to elevate to your attention is that emergency flexibility in funding for public health crises (in addition to and apart from Medicaid) is a key challenge in addressing SDOH. States must have waiver flexibility to address SDOH issues as they arise in terms of reimbursement of non-medical services by Medicaid, Medicare, or other traditional “health care” funding streams.

Is there a unique role technology can play to alleviate specific challenges (e.g. referrals to community resources, telehealth consultations with community resource partners, etc.)? What are the barriers to using technology in this way?

Leveraging telemedicine has shown great promise in lessening barriers to care by increasing access to services and reducing travel time and associated costs.[4] During the current public health emergency, the U.S. Department of Health and Human Services (HHS) temporarily expanded telehealth services by permitting Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to serve as distant telehealth sites and provide telehealth services to patients in their homes.[5] They expanded the types of services that may be delivered via telemedicine and reimbursed at equivalent rates as in-person visits as well. With some states choosing to discontinue this expanded telemedicine coverage as their public health emergency orders lift, others have enacted new laws to keep them intact. Left unaddressed by federal policy, this may result in uneven telemedicine coverage for Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) beneficiaries depending on where they live.

The continued provision of clinically appropriate telehealth services past the public health emergency period is especially important for residents of rural and frontier areas, people in communities disadvantaged by social and economic injustice, individuals with disabilities and severe chronic conditions, and those without reliable access to transportation. States can address patients’ common access barriers by financing telehealth services that are available in the most convenient format for patients (e.g., audio only), in patients’ primary language, and tailored to patients’ most pressing health and social needs. In order to maximize the potential benefits of expanded telehealth services, it is also essential to increase broadband access such that internet coverage is more consistent across the country.

Improving Alignment

Where do you see opportunities for better coordination and alignment between community organizations, public health entities, and health organizations? What role can Congress play in facilitating such coordination so that effective social determinant interventions can be developed?

According to a January 20, 2021 Executive Order, “the head of each agency, or designee, shall, in consultation with the Director of OMB, select certain of the agency’s programs and policies for a review that will assess whether underserved communities and their members face systemic barriers in accessing benefits and opportunities available pursuant to those policies and programs”. A publicly available status update on these federal agency equity assessments will promote transparency and overall accountability. Another opportunity for better coordination and alignment would be the formation of a White House-led interagency commission on SDOH that includes consumer/patient voices as well as representatives from Congress, federal agencies, and the Domestic Policy Council for Racial Justice and Equity.

What potential do you see in pooling funding from different sources to achieve aligned goals in addressing SDOH? How could Congress and federal agencies provide state and communities with more guidance regarding how they can blend or braid funds?

Section 1115 demonstration waivers are key mechanisms that several states have used to pool funds to address SDOH with the understanding these determinants impact downstream health care access, quality, and costs. Oregon and Colorado are great examples – each has regional entities that provide care by integrating physical, behavioral, and social services. States have also implemented Delivery System Reform Incentive Payments (DSRIP) to connect eligible providers with Medicaid funds for meeting metrics that can include supporting beneficiaries’ social service needs.

Arizona is a noteworthy example of a state using Medicaid funds to cover social service needs among program beneficiaries. The Arizona Health Care Cost Containment System (AHCCCS) requested an amendment to their Section 1115 Research and Demonstration waiver authority to implement a Housing and Health Opportunities Demonstration. This demonstration seeks to expand housing services and interventions for people who are homeless or at risk of becoming homeless. AHCCCS hopes these housing services will benefit the state’s Medicaid members by stabilizing mental health, reducing substance use, increasing use of primary care services, and decreasing emergency room, hospital, and crisis services as well as reducing homelessness in general. Specifically, the demonstration will, among other provisions, enable beneficiaries to receive Medicaid compensable, pre-housing wraparound services, rent or voucher assistance so they can rapidly secure housing and stay engaged in treatment, and eviction prevention services such as payment of back rent and late fees. This amendment to the demonstration is pending with the Centers for Medicare & Medicaid Services (CMS) following both state and federal public comment periods earlier this year.

There is significant potential for CMS to release guidance signaling further openness to waiver applications seeking to expand the number and depth of these demonstrations. CMS and the Center for Medicare and Medicaid Innovation (CMMI) can lead the development of additional models that blend and braid health system and social service funds that aim to address upstream determinants of health.

Are there any non-traditional partners that are critical to addressing SDOH that should be better aligned with the health sector to address SDOH across the continuum from birth through adulthood? What differences should be considered between non-health partners for adults’ social needs vs children’s social needs?

Health system fragmentation can lead to poor quality of care; inequities in care; frustrating experiences for adults, children, and families; and poor health outcomes.[6],[7],[8] When thinking beyond health care to all of the systems that serve children and families — including educational institutions, social services, and child welfare programs — the vision of achieving an integrated system to improve children’s health and wellbeing seems to be an even bigger challenge. States have already begun the work to coordinate key programs, services, and supports to implement a shared vision for children’s health and wellbeing. The following examples are models that Congress could incentivize further:

• Children’s Cabinets: Children’s cabinets, housed at the state or community level, are one mechanism to connect disparate systems that serve children. The goal of a children’s cabinet is to bring together a diverse set of stakeholders to develop and implement a shared vision for children and families in a community.[9] Other similar coordinating bodies include interagency councils and commissions, and early childhood councils.
• Federal Funding Opportunities: Federal funding streams, like Family First Prevention Services Act (FFPSA) or PDG B-5 grants, will serve children best as parts of an integrated approach, and they provide an opportunity to bring diverse stakeholders together and build a shared agenda. As states are awarded these grants, advocates can call for broad community involvement and motivate states to include diverse stakeholders, and develop programs that are responsive to community needs beyond the specific requirements of the federal funding.
• Separate Children’s Budgets: In the end, “what gets budgeted gets done,” and strategic state and local financing mechanisms are central to improving child health and outcomes. Pushing states to develop budgets that take a comprehensive view of children’s services and supports can help state and local leaders align existing funding, understand where gaps are in the system, and identify new funding opportunities.[10]

What opportunities exist to better collect, understand, leverage, and report SDOH data to link individuals to services to address their health and social needs and to empower communities to improve outcomes?

Leveraging SDOH data to measure and ultimately improve health outcomes remains a challenge for a variety of reasons, from the general lack of infrastructure for stratified health data to interoperability across federal agencies. One solution for streamlined data collection is through creation of a national all payers claims database (APCD), a database requiring both public and private payers to report health care utilization and claims data according to federally established standards across the following categories: medical and clinical, prescription drug, dental, behavioral health, available social services data, as well as prices charged for health care services.[11] While 23 states currently have APCDs, they are limited by the ability of self-insured group health plans to opt out of participation. Further, because these APCDs are state-administered, comparative analyses are complicated by each state having their own data submission protocols. HHS already has the regulatory authority and is collecting much of this data, so a national APCD would be a natural next step in being able to ensure sophisticated data analysis to make improvements in the cost, quality, and equitable distribution of health care.

Best Practices and Opportunities

What are some programs/emergency flexibilities your organization leveraged to better address SDOH during the pandemic (i.e., emergency funding, emergency waivers, etc.)? Of the changes made, which would you like to see continued post-COVID?

The COVID-19 pandemic catalyzed the integration of telehealth services into the mainstream of health care delivery and payment. As stay-at-home orders rippled through the country, driving down visit volume, and therefore revenue for providers across the country, many health care providers and health systems worked to ramp up their ability to deliver telehealth services. Telehealth quickly became both an essential tool for families to continue accessing needed health care services during the public health emergency (PHE) and a critical revenue generator for practices to keep their doors open in the wake of reduced in-person volume. Telehealth flexibilities have allowed the use of audio-only communications for the diagnosis, evaluation, or treatment of many health conditions and are critical to ensure audio-only services are continued beyond the pandemic. Expanding access to audio-only services equally to video services is critical to overcoming many of the barriers in accessing telehealth services for families, and ensures that families are able to receive needed health care services both for the duration of the public health emergency and beyond. Other services that should be extended beyond the public health emergency include remote patient monitoring.

Which innovative state, local, and/or private sector programs or practices addressing SDOH should Congress look into further that could potentially be leveraged more widely across other settings? Are there particular models or pilots that seek to address SDOH that could be successful in other areas, particularly rural, tribal or underserved communities?

The Health Equity and Accountability Act, introduced in the last Congress, has long been the highest-profile congressional vehicle for potential federal legislative reforms to address health disparities. With respect to state activity, several states are developing Medicaid health equity incentives as part of broader efforts to reform how health care is financed and organized in ways that are intended to improve population health in communities of color. These efforts began before the COVID-19 pandemic, but their importance is now amplified in light of the public health emergency.[12]

We recommend that Congress build on state innovations from Massachusetts, Oregon, Minnesota, and Washington State, all of which are summarized below in the section on “Transformative Actions”. Learning from these states, there are several national policy recommendations that show promise in addressing SDOH in health care programs:

• Build stratified health equity measurement into pay-for-performance programs at the federal and state level.
• Develop Medicare and Medicaid program capacity to intervene in social drivers of health, including flexible funding and structures, such as ACOs, to coordinate between CBOs, health plans, and health care providers. Dramatically increasing the scope and number of community health workers in our health system should be an important component of this strategy.
• Reform Medicare and Medicaid behavioral health benefits and network adequacy requirements.
• As a part of any major infrastructure package passed in 2021, increase federal investment in social services, early childhood education, economic opportunity, health care, environmental pollution, and preventing incarceration.[13]

Given the evidence base about the importance of the early years in influencing lifelong health trajectories, what are the most promising opportunities for addressing SDOH and promoting equity for children and families? What could Congress do to accelerate progress in addressing SDOH for the pediatric population?

Policymakers must recognize the long-term health, social, and economic benefits of upstream investments for children, including those who have experienced trauma, violence, or severe adversity, and fully include children in health care payment and delivery system reform. Below is a summary of recommendations Congress should consider to scale up payment models that make that will result in improved health outcomes and reduced costs to our health care and social service systems going forward.[14]

• Congress should mandate that CMS design and test new delivery and payment models exclusively focused on early intervention and prevention for children using evidence-based interventions. Congress should require that in designing these new models, CMS should expand CMMI’s statutorily defined goal of achieving short-term savings to include requirements that:
• A percentage of all short-term savings produced and certified by the CMS Office of the Actuary within tested payment models (e.g., 10%) be reinvested in upstream interventions aimed at longer-term health outcomes for children that will produce savings over the life course; and
• Models are prioritized that more effectively link payment to those same goals.
• The patient-centered medical home (PCMH) model has tremendous potential for savings and improved child health outcomes. However, broader pediatric medical homes have largely not been incorporated into PCMH frameworks for CMS and commercial insurers, missing an important opportunity to establish primary care as the foundation to comprehensive, coordinated care delivery with financial accountability not just for adults but also for children.[15]
• Congress should also mandate new preventive services under both Title XIX (Medicaid) and Title XXI (CHIP) of the Social Security Act for children exposed to adverse childhood experiences (ACEs). Those services may include evidence-based parenting classes, family peer support services, and expanded coverage and reimbursement for community health workers (CHWs) as culturally responsive liaisons between parents and pediatric care that can also help connect parents to needed social services.
• Congress may also improve the health trajectories of children by investing in maternal health, as a mother’s health during the prenatal, birth and postpartum period has a significant impact on the health of the child.[16]We strongly support expanding access to and integration of midwives, peer perinatal support workers, and other non-physician health professionals into the maternal health landscape, and building continuity and coordination of care to improve health outcomes.
• Congress should amend Title XIX of the Social Security Act to provide coverage under Medicaid for services provided by community-based doulas, perinatal community health workers, and other peer support service providers. The benefits of community-based doulas in maternity care are well-supported and demonstrated by research showing improved health outcomes for both women and babies including: fewer low birthweight babies, fewer preterm births, fewer cesarean sections, lower rates of postpartum depression, increased breastfeeding, and more positive birth experiences.[17] Medicaid coverage of these doula care services would not just facilitate access to this care for those who need it most; it would also improve short and long-term outcomes for both moms and babies. Perinatal CHWs serve as bridges between their communities and the health care system, fostering greater trust and enhancing the health system’s ability to provide higher quality, culturally centered care. Due to their intimate knowledge of their communities’ needs and resources, CHWs are particularly effective at addressing social determinants of health.[18]
• Congress should direct CMS to implement a demonstration program for freestanding birth centers to develop innovative and sustainable payment models for low-risk maternity care. In the CMS Strong Start program study, participants who received prenatal care in Strong Start birth centers were found to have lower rates of low birth weight, preterm birth, and C-sections and higher rates of vaginal birth after cesarean (VBAC) than other Medicaid beneficiaries. Birth center care has also been found to have the potential to save Medicaid an average of $11.6 million per 10,000 births per year and reduce costs per birth by 16 percent as compared to hospital care.[19]
• Congress should direct HHS to implement a maternity care demonstration project that includes doulas, CHWs and midwives, and is focused on reducing racial and ethnic disparities and improving health outcomes. Maternity care homes are another high-value care model that integrate comprehensive care and show promise in reducing racial disparities in maternal health outcomes.[20]Through maternity care homes, pregnant women are paired with care coordinators who can connect them to essential perinatal health care, as well as social and community services. This model addresses SDOH to reduce complications by providing coordinated, comprehensive, and culturally appropriate services and care, including mental health services and access to housing and food assistance.
• Congress should amend Title XIX to provide evidence-based home visiting services for pregnant and postpartum women, and their infants. Home visiting programs, which serve women and families during and after pregnancy, can promote maternal and child health by connecting mothers to postpartum medical care, mental health and substance use disorder treatment, and community-based resources; providing parenting education; and bringing clinical services into the home.[21]In addition, evidence-based home visiting programs reduce costs. Research has shown that home visiting programs reduce NICU stays and the costs associated with them and for every dollar invested in a home visiting program, there is a return of up to $5.70 in savings and benefits. In turn, the success of home visiting programs ultimately saves money for states and the federal government by lowering costs for programs such as Medicaid.[22] Ultimately, Medicaid reimbursement for home visiting services would improve health outcomes for pregnant women, babies and families, and provide meaningful cost savings to the health care system.

Transformative Actions

Alternative payment models help to measure health care based on its outcomes, rather than its services. What opportunities exist to expand SDOH interventions in outcome-based alternative payment models and bundled payment models?

States are developing Medicaid health equity incentives as part of broader efforts to reform how health care is financed and organized in ways that are intended to improve population health in communities of color.[23] The importance of these state programs lies both in their progress toward financial incentives for equity and in their broader approach to delivery system reform and the social determinants of health. New payment structures designed to improve health equity will fail if they are not embedded in broader reforms that address the conditions that perpetuate health inequities, including structural racism.

Washington State’s accountable communities of health (ACH) program is an important experiment in building regional Medicaid capacity separate from and alongside Medicaid-managed care. The ACH model is intended to create a community-based governance structure that includes but is not run by Medicaid-managed care, and that oversees both Medicaid-managed care contracting and coordinating health care and human services to address the social determinants of health. Washington’s ACHs are conducting projects across a range of focus areas aimed at reducing health inequities including the impact of structural racism on health and the social determinants of health and integrating physical and behavioral health systems.

A critical element of transformation, particularly for new models of care, is measurement and evaluation. With SDOH in mind, which are the most critical elements to measure in a model, and what differences should be considered when measuring SDOH outcomes for adults vs children?

Minnesota’s Medicaid provider-based Accountable Care Organizations (ACOs), called Integrated Health Partnerships (IHPs) are required to develop consumer-focused measures and milestones that target health-related social needs as part of their equity-focused interventions.[24] For example, IHPs have measured and reported on the percentage of patients who were screened for health-related social needs, the percentage of screened patients who report food insecurity, patient participation in patient satisfaction surveys, changes in patients’ social history outcomes following referral to social service providers, and the nature and frequency of patients’ use of emergency services. IHPs also report their progress in developing tracking systems, contracting with community-based social service providers, and hiring navigators and community health workers.

How can Congress best address the factors related to SDOH that influence overall health outcomes in rural, tribal, and/or underserved areas to improve health outcomes in these communities?

During this pandemic, families are relying heavily on digital devices for their education, health, and social needs. However, there is a digital divide — meaning some Americans have access to the latest digital technologies and reliable, high-speed internet, while others, especially low-income communities and older people of color, have low digital literacy and limited access to reliable internet and advanced technologies.[25] The major policy and regulatory changes states have made to expand telehealth capabilities have great potential to meet the needs of both patients and providers in rural, tribal, and/or underserved areas: however, telehealth financing and implementation, as well as patient access to telehealth services, must improve to truly influence health outcomes in these communities. More broadly, there must be new financial incentives that allow providers to be reimbursed for addressing SDOH in the form of prospective, ongoing capitated payments that eventually are entirely independent of FFS models.

What are the main barriers to programs addressing SDOH and promoting in the communities you serve? What should Congress consider when developing legislative solutions to address these challenges?

• Funding: Although Medicaid and Medicare funding have an important role in addressing SDOH, they are not panaceas. Federal and state investments—across multiple federal and state agencies and focused on key sectors including social services, education, economic opportunity, health care, environmental pollution, and reduced incarceration among others—are needed to enable the health care system to center equity within its enterprise and advance racial justice. We believe the Build Back Better Act currently under consideration is an important legislative effort to move forward in this comprehensive way.

As to state investments, a number of states are beginning to shift some health care funds in Medicaid and public health agencies into SDOH.[26] The critical questions surrounding these state efforts are not about technical design but rather the scope of underlying reforms. Can states sufficiently reshape health care delivery to improve equity outcomes? Even more difficult—can states address the social injustice and inequality that cause disparities in population health? The second question, in particular, indicates a need for federal action in concert with states to address inequities in social determinants of health.

One important tool that Congress can utilize to drive both Medicare and Medicaid funding is the Center for Medicare and Medicaid Innovation. Congress should create a new CMMI legislative mandate to invest $10 billion over 10 years in nonmedical services that drive population and individual health and wellness. Services should include supportive housing, nutrition, transportation, prevention of interpersonal violence and adverse childhood experiences, and environmental safety interventions. This effort should work with the Center for Medicaid and CHIP Services and state Medicaid agencies to provide greater flexibility, incentives, and, especially for the safety net, resources for health care providers and plans to coordinate with social service providers and community-based organizations with Medicaid funds.

• Administrative Infrastructure: Action on social drivers of health requires coordination at the local or regional level, ideally through a multisector stakeholder advisory group with strong representation from target communities. Connecting health care providers from different types of health delivery, and then connecting the health and social service sectors, is a significant undertaking and necessitates flexibility to better meet people’s health needs. In most places, these connections will require new multisector stakeholder advisory groups with some level of dedicated staff support.

CMS has in some states invested in this administrative and coordination infrastructure under Medicaid waiver authority. But these waiver-based investments are not feasible in many states because of the idiosyncrasies of Medicaid waiver budget neutrality rules and other state-specific factors like the availability of intergovernmental transfers from public hospitals to fund state share. Congress could consider a more equitable funding source to support the administration of federal and state investments in SDOH.

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[1] “California Takes Steps to Move Its Health Care System Toward Health Equity and Social Justice,”

[2] Murphy, K. et al. Equity in COVID-19 Vaccines: Emerging Lessons from the Front Lines (2021). Retrieved from https://familiesusa.org/wp-content/uploads/2021/04/HE-2021-102-Vaccine-Equity_v3.pdf. 

[3] Burroughs, M. et al. What’s at Stake for America’s Families: Why Congress Must Go Big and Bold in Reconciliation to Improve Health and Health Care for Millions of People (2021). Retrieved from: https://familiesusa.org/wp-content/uploads/2021/09/COV-2021-262_Whats-at-Stake-Report.pdf.

[4] Taylor-Penn, L. et al. Advancing Health Equity through Telehealth Interventions during COVID-19 and Beyond: Policy Recommendations and Promising State Models (2020). Retrieved from: https://familiesusa.org/wp-content/uploads/2020/07/HE-98_-Policy-PCORI-Telehealth-_Issue-Brief_7-22-20.pdf.

[5] “Telehealth: Delivering Care Safely During COVID-19”. U.S. Department of Health & Human Services, Accessed September 21, 2021. https://www.hhs.gov/coronavirus/telehealth/index.html.  

[6] Kurt Stanger, “The Problem of Fragmentation and the Need for Integrative Solutions,” Annals of Family Medicine 7 (2009):100-103,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653966/pdf/0060100.pdf.

[7] K. Mate and A. Compton-Phillips, “The Antidote to Fragmented Healthcare,” Harvard Business Review, Vol. 92 No. 12., (2014), https://hbr.org/2014/12/the-antidote-to-fragmented-health-care.

[8] J. Stanger, K. Stanger, and L. Letups, “Variability In States’ Coverage of Children with Medical Complexity Through Home- and Community-Based Services Waivers,” Health Affairs 38, no. 9 (2019): 1484-1490, https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05413.

[9] E. Gaines, O. Allen, and A. Vaughn, Children’s Cabinet Toolkit: A Roadmap for Getting Started in Your Community (Cambridge, MA: Education Redesign Lab, 2019). https://forumfyi.org/knowledge-center/childrens-cabinet-toolkit/.

[10] A. Wilson-Ahlstrom, E. Gaines, N. Ross, and K. Pittman, Funding Brighter Futures: How Local Governments Are Enhancing Investments in Kids (The Forum for Youth Investment, 2017). http://www.fundingthenextgeneration.org/nextgenwp/wp-content/uploads/2017/10/funding_brighter_futures_discussion_paper-2.pdf.

[11] Families-USA-OMB-RFI-Comment-Letter-210706.pdf (familiesusa.org)

[12] “To Advance Health Equity, Federal Policy Makers Should Build On Lessons From State Medicaid Experiments”, Sophia Tripoli and Eliot Fishman, Health Affairs, April 2021.

[13] “To Advance Health Equity, Federal Policy Makers Should Build On Lessons From State Medicaid Experiments”, Sophia Tripoli and Eliot Fishman, Health Affairs, April 2021.

[14] Health Care Payment and Delivery System Reform for Children as a Tool to Improve the Health of Vulnerable Communities (2020). Retrieved from: https://familiesusa.org/wp-content/uploads/2020/07/CHI_Kids-System-Transformation_FINAL.pdf. 

[15] Centers for Medicare & Medicaid Services, “Pediatric Alternative Payment Model Opportunities: General Information,” last updated January 8, 2020, https://innovation.cms.gov/initiatives/pediatric-apm.

[16] “Healthy Mother, Healthy Newborn: Linking Essential Services for Mother and Baby Across the Continuum of Care,” World Health Organization, Accessed September 15, 2021, https://www.who.int/pmnch/media/news/2012/mnh_card.pdf.

[17] Asteir Bey et al. Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities (New York: Ancient Song Doula Services; Village Birth International; Every Mother Counts, 2019), Retrieved from: https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf

[18] Ruff, E. et al. Advancing Health Equity through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations (2019). Retrieved from: https://familiesusa.org/wp-content/uploads/2019/11/HEV_PCORI-CHW-Report_11-04-19.pdf

[19] Embry Howell, Ashley Palmer, Sarah Benetar, and Bowen Garrett. (2014). Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center. Medicare Medicaid Res Rev, 4(3), mmrr2014-004-03-a06. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167228/

[20] Committee on Assessing Health Outcomes by Birth Settings, Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education, Health and Medicine Division, & National Academies of Sciences, Engineering, and Medicine. (2020). Birth Settings in America: Outcomes, Quality, Access, and Choice (S. Scrimshaw & E. P. Backes, Eds.). National Academies Press. Retrieved from: https://doi.org/10.17226/25636

[21] Boozang P, Brooks-LaSure C, Guyer J. Medicaid’s Crucial Role in Combatting the Maternal Mortality and Morbidity Crisis. 2020. Retrieved from: https://www.shvs.org/wp-content/uploads/2020/03/FINAL_-Medicaids-Crucial-Role-in-Combating-the-Maternal-Mortality-and-Morbidity-Crisis.pdf

[22] Herzfeldt-Kamprath R, Calsyn M, Huelskoetter T. Medicaid and Home Visiting. Center for American Progress. (2017). Retrieved from: https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/

[23] “To Advance Health Equity, Federal Policy Makers Should Build On Lessons From State Medicaid Experiments”, Sophia Tripoli and Eliot Fishman, Health Affairs, April 2021.

[24] Ruff, E. et al. Making Progress Toward Health Equity: Opportunities for State Policymakers to Recue Health Inequities Through Payment and Delivery System Reform (2020). Retrieved from: https://familiesusa.org/wp-content/uploads/2020/12/HE-12_Making-Progress-toward-Equity-Issue-Brief_12-18-20.pdf.

[25] Velasquez and Mehrotra, “Ensuring the Growth of Telehealth during COVID-19.”

[26] “To Advance Health Equity, Federal Policy Makers Should Build On Lessons From State Medicaid Experiments”, Sophia Tripoli and Eliot Fishman, Health Affairs, April 2021.